Age: 49.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Magnetic resonance imaging neck, Magnetic resonance imaging spinal, Metabolic function test, Migraine, Muscle atrophy
Clinical narrative: Degenerative nerve syndrome or disorder - first symptoms developed 2 weeks after 2nd dose of Pfizer intractable headache on the right occipital side of his head that turned into a migraine with exertion. Discovered a hypersensitive patch of skin on the interior of his right knee that when agitated by clothes, movement, temperature, or touch caused the headache, described as atypical allodynia. It was able to be mitigated by wearing shorts, decreasing movement and changes in lifestyle. No medication helped. Eventually, the allodynia faded but muscle twitches and spasms as well as severe hand tremors became worse. Severe, pronounced and sudden onset of muscle atrophy on left arm and hand.  PASC patient with marked change in symptoms after 2nd dose of Pfizer  Symptoms: Intractable headache, migraine, atypical allodynia, muscle spasms and tremors, severe chronic fatigue, difficulty sleeping, occasional tinnitis.   1/30/21 Woke up with pain in neck that turned into an intractable headache that was only relieved when in supine position. He experienced a constant dull ache with sharp pain in the back of the head when standing from sitting, walking, and going up steps. No medications or treatments worked.  4/21 After 2 months of constant severe headache at a pain level of 6, discovered patch of hypersensitive skin on inside of right knee that when touched caused head pain. He was able to reduce the pain level down to a 0 by wearing shorts within an hour. Atypical Allodynia was thermal, tactile/static, and mechanical. Would wake up with a migraine if patient slept with knee touching anything. No pain in knee, only occassional pinpricking. Inverse pain relationship - the lighter the touch, the sharper the pain.  8/21 Static Allodynia slowly faded. Started noticing weakness in the arms. Muscle loss. Patient used to do pull-ups and push-ups every morning. Can no longer do. Loss of grip strength. 24/7 muscle spasms in arms and torso, hand tremors, continued residual anosmia changes in smell, brain fog, severe fatigue after minor exertion, difficulty sleeping. Most medications do not help. Sumaptriptan, Butalbital and Nurtec helped with migraines. Nothing for nerve pain.  9/21 Severe Muscle Atrophy of left arm and hand, constant muscle spasms in arms and torso, hand tremors worsening 10/13/21 Worsening and pronounced muscle atrophy of left arm and beginning to move to right arm  Covid Tested Positive for Covid: July 18, 2020 Tested Negative for Covid: August 28, 2020 First wave of Symptoms (July 17  August 7) symptoms: headache, anosmia, aches, pains, brain fog, fatigue, appetite loss, difficulty regulating temperature, numbness and tingling. No hospitalization. Second wave of Symptoms (August 7  September 9) symptoms: GI, aches, pains, brain fog, fatigue, severe appetite loss, difficulty regulating temperature, numbness and tingling. No hospitalization.   Vaccination  Pfizer Vaccination 1st Dose: December 22, 2020  Symptoms: chills, aches, pains, headache, arm pain  Pfizer Vaccination 2nd Dose: January 12, 2021 Symptoms: severes chills (shaking lasted over an hour), no fever, worse muscle aches and pains, severe headache, arm pain, difficulty with temperature regulation, hands and feet cold to touch, reaction lasted 48 hours  Onset of Chronic Intractible Headache: January 30, 2021   Diagnostics  MRI of Head 2/18/21 MRI Neck and Spine 03/17/21 MRA of Neck (Osteophytes, Stenosis, and Moderate degenerative arthritis)3/17/21 X-Ray of Right Knee and Lower Back 05/06/21 Nerve Conduction Study of Left side only 05/19/21 Ultrasound of Right Knee - 08/20/21 2nd Nerve Conduction Study of 4 Extremities, Thoracic and Tongue - scheduled 10/25/21  Labs  02/22/21 Lipid, B12 (1157H), LDL (112H), HDL (39L) Non HDL (137 H) Comprehensive Metabolic Panel, Hemoglobin, TSH, CBC, Hep C, HIV, RPR (DX) w/ REFL Titer 03/30/21 Salicylate, ANA, C-Reactive Protein 05/06/21 B6, Plasma (22.8) Iron, B1, Ferritin, Folate 07/16/21 Renal Function Panel 09/17/21 CRP, Sed Rate, B12, Folate, Homocysteine Total 10/09/21 CK, RFP, CBC w/ Auto Diff with Platelets  Doctors & Specialists: Primary Care, 3 Neurologists, Dermatologist, Pain Management Specialist  Medications tried: Advil, Acetaminophen, Meloxicam 15mg, Fluticasone Spr 50Mcg, Nurtec, Butalbital/Caffeine/Acetaminophen Tab, Cyclobenzapr 5Mg, Nabumetone500Mg, Tizanidine Cap 4Mg, Gabapentin300Mg, Baclofen Tab 5Mg, Sumatriptan Tab 100Mg, Duloxutine, Amitriptyline, Hydroxyz Hcl Tab 25Mg  FMLA and Short Term Disability began on 5/10/21 - PCP extended disability through 5/10/22.