Age: 38.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Spinal pain, Trigeminal neuralgia, Urine abnormality, Urine analysis abnormal, Urine ketone body present
Clinical narrative: I am a nurse practitioner, so as a healthcare worker, I received a very early vaccine. I have had little time to report what happened to me but not that it remains an issue I think I need to do so.  I had a very serious initial reaction and am now having chronic problems likely related to my vaccine. I received my first dose of Moderna 12/27/20 at POD lot# 025J20A and my second dose 1/24/21 at POD lot#029L20A.  After the first vaccine within a few hours I had significant injection site and arm pain. By the time I went to bed that night I could barely lift my arm over my head it was so stiff and warm. The arm was very painful, and I required Ibuprofen 800 mg TID for 3 days to control the pain. I did not have systemic symptoms from the first vaccine. After the second vaccine, within hours I had systemic symptoms of fatigue, generalized aches in my muscles and severe arm pain in the injection arm. I received the vaccine in the afternoon. I went to bed that night and woke up suddenly at 3 am, about 14 hours later. I had severe myalgias and rigors. I was barely able to move. I was not able to walk or perform fine or gross motor tasks without difficulty. I was unable to dress myself or get up to go to the bathroom. I required almost fulltime care from my husband for three days. On day 4 I developed severe headaches nausea and vomiting. The muscles still ached but I was able to walk and move again. My fine motor was still impaired for a total of 7 days. I was out of work for 8 days and did not feel 100% well for 12-14 days after the vaccine. As the symptoms started to resolve on day 5, I believe I had a mild case of Rhabdomyolysis as my urine was very dark almost brown and there was sediment in the toilet. There was no blood in my urine and no dysuria. I did a urine dip at work and it had protein and ketones but no bacteria. The specific gravity was very concentrated. I did not check my renal function at that time. My renal function a few weeks later was normal Cr 0.88. GFR 85. The dark urine and sediment lasted for about 2-3 days. I was drinking lots of water through this time-period and during then I was very ill. I was not seen at a hospital and rather I treated myself at home. During the above week was the first time I ever had neck or back pain. It did subside but I still had a dull aching in my neck after all of this. I had two episodes, one in late January and one in mid-February of left neck being very sensitive to touch, felt warm, and my ear was very hypersensitive to touch as well. It felt almost like shingles but there was never a rash and I took Acyclovir 800 mg TID for 3-5 days without relief. It subsided each time after about 7 days. This was on the same side of my body on the left as the vaccine was. In the end of March 2021 I began with left trapezoid pain in the same side of the body. I had some numbness in that arm as well so I saw orthopedics and received an MRI of my left brachial plexus which showed C3-4, C4-5, and C6-7 disc herniations that had not been present before. If the herniations were present in the past they were acutely inflamed by the inflammatory process the vaccine caused in my body. The MRI also showed significant and specifically left cervical and left axillary adenopathy this being the side of my vaccine. The pain spread beyond my trapezoid and become progressively worse into my neck and upper back only on the left side. The entire left side of my spine both cervical and thoracic was painful but the right side unaffected. It was very sharp nerve like pain shooting and running up into my head and anterior neck. Another MRI was done of the full cervical spine this time confirming these same herniations, but the discs appear to be pulling to the left with isolated left inflammatory process. The nerve pain became so severe that last week I began having numbness in that left arm and numbness into the left side of my face. A stat MRI of my brain only shows T2 flare pattern consistent with sequela of an inflammatory process of unknown origin. The foraminal stenosis at these spinal levels are very mild and do not explain my symptoms very well. Spine specialist reports that there can be symptoms of this nature but usually not with this mild of a pathology. The facial numbness has been identified as a trigeminal neuropathy of cervical origin but is rarely documented in medical journals and not seen by these spine specialists. There is a very significant amount of left sided nerve over stimulation, inflammation and adenopathy that is not explained. I have never had any spine or neck pain in my life before this and I have no history of traumatic events to explain this sudden change in my condition. I truly feel that ever since I received the Moderna vaccine and had that very severe reaction, my body has been in a constant inflammatory phase and there has been nerve pain in and around only the left upper side of my body where the vaccine was placed. I am scheduled on Monday for epidural spinal injections as I have been unable to find pain relief with any other therapies including dry needling, physical therapy, traction, tramadol, muscle relaxers, oral steroid bursts, etc. I know this may be a very strange and unique case, but I can say confidently that I believe the vaccine stimulated this entire cascade of events. If someone could please contact me related to this, I would appreciate it.