Age: 13.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Blood glucose normal, Blood homocysteine normal, Blood lactic acid, Blood phosphorus decreased, Blood potassium normal
Clinical narrative: ICC visit 1/8/22  patient has been sick since yesterday, with  vomiting,diarrhoea , chills ( no fever )  headache, sore throat.ea ache  bodyaches, clear runny nose, dry cough, SOB,  has asthma Mom  states she is exposed to COVID-19 and patient wants to get tested for COVID -19    1/14/22  ED note:Presented due to tender nodules on bilateral arms. Patient developed COVID symptoms 1/7 and tested positive the next day. She received sotrovimav 1/9 with improvement in symptoms two days later; however, two days ago, she developed a sharp pain in the right AC and realized there was a nodule there. She also developed nausea, vomiting, decreased PO intake, abdominal pain, and orange urine. She has been treating with zofran, tylenol, and motrin at home. She then developed a second nodule on her L forearm yesterday and a third nodule on her L AC this AM. ID and pharmacy were contacted yesterday but have not heard of nodules occurring with sotrovimav infusions. Of note, IV for infusion was in the right hand. No hx of blood clots but patient on birth control.   On exam, nodules are tender to palpation (clinical photography in chart). She complains of right sided abdominal pain but abdomen soft. No lymphadenopathy. No fever since initial COVID symptoms began prior to infusion.   Acetaminophen (TYLENOL PO) Take by mouth.       albuterol HFA 108 (90 Base) MCG/ACT inhaler Inhale 4 puffs into the lungs every 4 (four) hours as needed for Wheezing or Shortness of Air     cetirizine (ZYRTEC) 10 MG tablet Take 40 mg by mouth 20 mg AM 20 MG PM.        Cholecalciferol 250 MCG (10000 UT) CAPS Take 250 mcg by mouth daily.      clindamycin (CLINDAGEL) 1 % gel APPLY TO AFFECTED AREA TWICE DAILY   cyclobenzaprine (FLEXERIL) 5 MG tablet Take 1 tablet by mouth 2 (two) times daily as needed for Muscle spasms.   EPINEPHrine (EPIPEN) 0.3 MG/0.3ML SOL A-IJ use as directed by prescriber for ALLERGIC REACTION      famotidine (PEPCID) 20 MG tablet Take 20 mg by mouth 2 (two) times daily.      ferrous gluconate (FERGON) 324 MG tablet Take 1 tablet by mouth 2 (two) times daily.   levonorgestrel-ethinyl estradiol (SEASONALE) 0.15-0.03 MG Take 1 tablet by mouth daily Take in a continuous manner, skipping placebo week and moving directly to next new pack    meloxicam (MOBIC) 7.5 MG tablet Take 1 tablet by mouth daily.  midodrine (PROAMATINE) 5 MG tablet Take 1 tablet by mouth Twice a Day for 7 days, THEN 2 tablets Twice a Day. Afternoon dose no later than 4 :00 pm. (Patient taking differently: THEN 2 tablets Twice a Day. Afternoon dose no later than 4 :00 pm.)  montelukast (SINGULAIR) 5 MG chewable tablet Chew 5 mg by mouth nightly .        polyethylene glycol (GLYCOLAX) powder Take 17 g by mouth as needed for Constipation : Mix in 4 oz of water/juice/milk.      rizatriptan (MAXALT) 10 MG tablet Take 1 tablet by mouth as needed for Migraine, may repeat once in 2 hrs - max 30 mg/24 hrs.   Spacer/Aero-Holding Chambers DEVICE Use 1 each as needed (For use with albuterol inhaler)   tiotropium (SPIRIVA RESPIMAT) 1.25 MCG/ACT AERS inhalation Inhale 1 puff into the lungs nightly .        topiramate (TOPAMAX) 25 MG tablet Take 1 tablet by mouth 2 (two) times daily for 7 days, THEN 2 tablets 2 (two) times daily.   traZODone (DESYREL) 50 MG tablet Take 1 tablet by mouth nightly  triamcinolone (KENALOG) 0.1 % ointment Apply topically 2 (two) times daily to affected area(s) of bilateral axilla twice a day for up to 2 weeks as needed.   triamcinolone (NASACORT ALLERGY 24HR) 55 MCG/ACT nasal inhaler Instill 2 sprays into nose 2 (two) times daily 2 spray every day and she can use 4 spray PRN.        WIXELA INHUB 250-50 MCG/DOSE AEPB inhaler INL 1 PUFF PO Q 12 HOURS. RM AFTER U      1/17/22-dischaHospital Course (by problem): Thrombophlebitis On admission, she had a exquisitely tender nodules without overlying erythema or rash in the superior aspect of the right antecubital fossa, left antecubital fossa, and anterior aspect of left forearm. The left forearm nodule had a hyperpigmented streak starting at the nodule and extending toward the hand. Her differential included nodular lymphangitis felt less likely due to lack of exposures and BL findings, new viral infection such as EBV, CMV, complications of the COVID itself or a reaction to her Sotrovimab. A Hepatitis panel was negative and EBV and CMV titers were sent and serial CMPs were ordered. She was initially just admitted on motrin prn with her home medications, PO ad lib and MIVFs. Infectious Disease and Heme Onc were consulted. By the next morning, her physical exam was notable for an "L" shaped hyperpigmented, painful lesion on the left forearm and this and her other lesions seemed more hard and cord like more so than mobile nodules or lymph nodes. Given this and the fact that she had multiple risk factors for increase risk of clotting (lupus anticoagulant, obesity, birth control, acute COVID-19 infection, and venous stasis), physical exam findings were felt to be most consistent with superficial thrombophlebitis. Pediatric ID and Heme/Onc agreed. A hypercoagulable work-up was initiated and she was started on Lovenox 40mg BID (prophylactic dose) for at least 2 weeks, stopping her estrogen-containing birth control during this time. She did develop some posterior calf and BL foot pain with a cord over her R foot and BL foot hyperpigmented streaking but these rapidly resolved and her UE lesions greatly improved. She'd also remained afebrile in house and repeat BL LE doppler was also again negative. By the day of discharge she had only some improving L forearm pain with improved TTP and discoloration and only mild BL AC TTP with minimal remaining masses with superficial changes.  Heme Onc thus did not feel she needed increased to therapeutic dosing or Anti-Xa levels. Her mother, pharmacy, ID and Heme Onc were all okay with discharge to home. Her mother, already familiar with giving her sister injections for eczema, was easily able to take over her Lovenox injection in house and voiced comfort with doing so at home. She was then sent home in good condition. Her d-dimer was only mildly elevated at 612 and her homocyteine and ATIII had resulted as nml with Prothrombin, Factor V Leiden, Lipoprotein A, Pro C and Pro S as well as her EBV and CMV titers all still pending at the time of discharge.  She will be followed up in 2 weeks at Hematology and ID. The length of her Lovenox and hold on OCPs will be readdressed at that time.   Transaminitis with hyperbili and mild hypoalbuminemia on RUQ Pain, N/V, poor PO On admission, Hepatitis panel was normal and EBV/CMV testing were still in process at the time of discharge. Transaminitis was felt to be secondary to viral infection versus regular tylenol use during her COVID-19 infection versus COVID-19 itself. Throughout admission, CMP were trended. Her bili normlized, her alb dipped to 3.3 but was back up to 3.7 and AST and ALT downtrended to 82 and 526 respectively. Her RUQ tenderness improved some and then stabilized, her N/V resolved and her oral intake improved. She will continue to avoid tylenol (and motrin given her Lovenox) and needs another repeat CMP on 1/19/22 to continue to follow.   Mild Hyperchloremic Acidosis on Dehydration Her Cl- bumped to 115 likely from her IVFs with a likely related mild acidosis to 19. Ketosis and her dehydration may have played roles as well. Her UOP normalized and her PO intake improved as above. She was off IVFs by HD#2. Her Cl and HCO3 improved to stable at 110 and 18 on last checks.    Abnormal urine Her nurse noted some possible urine sediment on the night prior to d/c. Her UA was abnormal with moderate LE, 4 WBCs and trace bacteria but as she was not having any symptoms of a UTI this was not cultured. Repeat UA by her PMD is recommended. Of note her urobili was negative and her orange urine color change had resolved however as expect as her her hyperbili resolved and with hydration.   Significant Hospital Labs:      1/14/2022 09:31 1/15/2022 04:49 1/15/2022 16:19 1/16/2022 05:37 1/17/2022 04:44 C-Reactive Protein       <0.1 <0.1 Sodium 142 143 143 140 142 Potassium 3.6 3.7 4.2 4.1 4.0 Chloride 109 (H) 113 (H) 115 (H) 112 (H) 110 (H) CO2 22 22 19 (L) 22 18 (L) Glucose 111 (H) 88 101 (H) 103 (H) 107 (H) BUN 7 6 (L) 7 11 10 Creatinine 0.59 0.57 0.60 0.57 0.58 Total Protein 7.0 6.1 (L)   6.1 (L) 6.7 (L) Albumin 3.9 (L) 3.3 (L) 3.5 (L) 3.3 (L) 3.7 (L) Globulin 3.1 2.8   2.8 3.0 Calcium 9.8 8.8 8.8 9.0 9.5 Bilirubin-Total 0.9 (H) 0.8 (H)   0.4 0.4 ALT/SGPT 1,020 (H) 967 (H)   723 (H) 526 (H) AST/SGOT 442 (H) 431 (H)   173 (H) 82 (H) Alkaline Phosphatase 89 76   73 77 Phosphorus     3.5     Homocysteine     7.0     Amylase 24 (L)         Lipase 15             1/14/2022 11:00 1/15/2022 17:34 1/16/2022 11:16 PT 11.9     INR 1.0     PTT 31.7     D-Dimer Quantitative   612 (H)   AntiThromb III Func   114   Heparin LMW     0.29     1/15/2022 04:49 Hepatitis A IgM Ab Nonreactive Hepatitis B Surface Ag Nonreactive Hepatitis B Core Ab(IgM) Nonreactive Hepatitis C Ab Nonreactive     1/14/2022 09:31 WBC 5.00 RBC 4.88 HGB 13.1 HCT 39.4 MCV 80.7 MCH 26.8 MCHC 33.2 Platelet Count 403   Significant Hospital Imaging/Diagnostic Tests:  Duplex US Venous Bilateral LE (1/14) Impression: No evidence of deep veinous thrombosis involving either lower extremity.   Duplex US Venous Bilateral UE (1/14) IMPRESSION:  No evidence of upper extremity deep venous thrombosis.    Duplex US Venous Bilateral LE (1/16) IMPRESSION: No obvious evidence of thrombosis noted in the imaged part of bilateral lower extremities veins as described above.    Abdominal US (1/14) FINDINGS: The liver demonstrates normal echotexture without focal defect or mass evident. Common duct is normal measuring 2 mm. Gallbladder is within normal limits for appearance. Visualized pancreas is unremarkable. Tail of pancreas is obscured by bowel gas.  Kidneys are normal size measuring 9.6 cm on the right and 10.6 cm in length on the left. No renal mass lesion is visible. No hydronephrosis seen. Spleen demonstrate normal echotexture measuring 9.6 cm . Doppler evaluation demonstrates that the hepatic veins are patent. The portal vein is also patent and demonstrates normal direction of flow. Normal resistive index and waveform of the hepatic artery. IVC and aorta are grossly patent. Bladder demonstrates normal contour.   IMPRESSION: No significant abnormality is identified.