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Life Threatening? No
Write-up: information is a verbal report from spouse, onset of illness 32 days after vaccination, treated by primary care MD, thought he had a virus, became blind by 11/21/07, continued deterioration to death. Autospy preformed: found patient had a demylinating process as cause of death. 05/27/08 Autopsy report reviewed which states COD as presumed acute pneumonia (autopsy limited to examination of brain). Report also states clinical hx of acute respiratory failure, febrile illness & staph aureus & e.coli dx on bronchoalveolar lavage 1/14/08. Other contributing conditions included: acute aggressive multifocal demyelinating disease w/white matter lesions multiple areas of the brain including previous biopsy sites & cervical spinal cord; cerebral atrophy & edema. 9/26/08 Reviewed hospital medical records of 1/3-/-19/2008. FINAL DX: multiple CNS lesions w/gadolinium-enhancing CNS lesions; myalgia; hypoxic respiratory failure; dysphagia; poor oral intake; nutrition; possible pneumonia; prophylaxis. Records reveal patient experienced re-admission for brain biopsy which revealed acute demyelinating process. Failed high dose steroids & plasma exchange. Tx w/mitoxantrone treatment & second course of high dose steroids in ICU. Mental & respiratory status deteriorated, significant muscle spasms & pain. Mechanical ventilation. Brain lesions continued to grow & new lesions appeared. Developed decerebrate posturing. Comfort care only decided & transferred to hospital closer to family home. 5/23/08 Reviewed initial eye clinic records of 11/29-11/30/2007 FINAL DX: probable retrobulbar ischemic ACON. Records reveal patient experienced HA x 3 days & blurred vision x 1 day. Patient had viral infection w/fever approx 10 days prior & still has sore eyes & stiff neck. Referred to neuro-ophthal. 6/6/08 Reviewed neuro-optho medical records for 11/30-12/2/2007. FINAL DX: bilateral optic neuritis Records reveal patient seen in clinic 11/30 emergently & admitted to hospital same day. Had used Cialis & noted difficulty reading next AM w/HA. Then developed blurry vision, decreased vision & pain over 3 days. Exam revealed visual acuity hand motion in right eye & 4/200 left eye, IOP WNL, no ptosis, slit lamp WNL, fundus w/1(+) edema of right optic nerve & trace edema left optic nerve. Admitted for stat MRI & IV steroids. No improvement & D/C to home on continued tapering steroids. 7/4/08 Reviewed hospital medical records of 11/30-12/02/2007 which were previously included in clinic records. FINAL DX: bilateral optic neuritis
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