Age: 44.0
Sex: F
Vaccine: COVID19
Symptoms: Chest X-ray normal, Delirium, Dyskinesia, Electroencephalogram abnormal, Endotracheal intubation
Clinical narrative: I saw patient for a telehealth visit on 8/17/21  she had runny nose/cough and I recommended she get a COVID test which she endorsed planning to get at Pharmacy later that day.  It's not entirely clear what happened in the interim as her memory from this point is not clear and she made no contact with our clinic in the interim but she then presented to the ED for altered mental status on 8/28.  Per hospital records, hospital course was as follows: "44-year-old female with a history of hypertension, OUD on Suboxone, Anxiety, non-insulin-dependent type 2 diabetes, macular degeneration, OSA and neuropathy who presented to the ED for altered mental status. Initially, patient was severely altered and agitated making history difficult. Per her husband she had had an episode of staring followed by unresponsiveness and thrashing about. When EMS arrived for her she was very agitated and delirious. Required benzos, Versed and ketamine in order to sedate her. On arrival to the ED she was severely hypertensive with SBP greater than 200. Admission was requested due to concern of altered mental status in relation to this high blood pressure. Immediately on arrival to the floor she subsequently went on to have 2 seizures, one witnessed, and a significant post ictal state and subsequent agitation that required multiple doses of Ativan and eventually intubation for airway protection. She was subsequently transferred to the ICU. Neurology was consulted who felt that her seizures were likely secondary to hypertensive encephalopathy. She underwent an EEG that showed diffuse slowing consistent with encephalopathy but no seizures at that time. She also had an MRI that did show edema in the posterior aspect. With all of this information together and her current presentation she was diagnosed with posterior reversible encephalopathy syndrome secondary to hypertensive emergency. After about 24 to 48 hours she was able to adequately follow commands and was extubated on 8/31. Patient had strict parameters for blood pressure control for systolic less than 140 which were initially managed with as needed's. She was eventually started on nicardipine drip. Other resultant abnormalities secondary to her seizures include acute renal failure with a peak creatinine of 3 (urine studies consistent with ATN) and metabolic acidosis secondary to lactic acid buildup. These both quickly improved over the next 2 days with bicarb and IVF. During this time she also had a fever to 100.7 (unrelated to recent seizure) which raise suspicion for aspiration. She is empirically started on Unasyn. Over the next couple days she had clear chest x-rays and no further fevers so antibiotics were stopped. Despite being extubated she continued to have significant agitation so was maintained on a Precedex drip and a PICC was placed for her nicardipine GTT. Finally on 9/2 her mental status had improved and she was able to be weaned off Precedex, passed a swallow study. Transition to oral antihypertensives was begun. She was started on amlodipine 10 mg, lisinopril 10 mg, HCTZ 12.5 mg and carvedilol 3.125 mg BID. Over the next 24 hours her blood pressure slowly began to normalize and nicardipine drip was turned off on 9/3. She was subsequently transferred out of the ICU. BPs largely stabilized on following regimen: Amlodipine 10 mg, lisinopril 20 mg nightly, HCTZ 25 mg, carvedilol 12.5 twice daily. Neurology signed off, recommended she continue taking Vimpat 100 mg twice daily. Her blood pressure goal is SBP less than 140. Neurology will follow up with her outpatient in 3 months, will determine need for continued antiseizure medication at that time. She was advised to not drive until seizure-free for 6 months. She was discharged home in stable condition on 9/6/2021. She will follow up with her PCP on 9/14/2021 to recheck blood pressures, adjust medications as needed, repeat BMP. "  Hospital recommendations to PCP included: "If able to verify timing of Covid vaccination in relation to seizure, consider if needs to be reported to the VAERS. Patient was unclear of exact timing, did obtain second Covid vaccination at Pharmacy somewhere between 2 to 10 days prior to hospitalization"  Per discussion with patient on 9/14/21, she believes she received vaccination (COVID19 Moderna #2)  shortly before symptoms started, I confirmed with Pharmacy staff she got vaccine 8/17, not known if she had a COVID19 test before she got the vaccine. nor was patient remember if she had a COVID test (as had been recommended on 8/17 at televisit due to her symptoms) She thinks she got fogginess mentally within a few days and that she then likely was not taking her routine medications in the time leading up to her presentation to the ED on 8/28 (11 days after vaccination but symptoms starting sooner).