Age: 33.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Encephalopathy, Endotracheal intubation, Fungal test, Gait disturbance, Gastrostomy
Clinical narrative: The patient is a 33 year old woman with PMH of hypothyroidism, small fiber peripheral neuropathy with regular IVIG treatment, depression, anxiety, celiac disease, ADHD, Lyme disease who presented with progressive encephalopathy.  On 4/9/21 she received the J and J vaccine. On 4/20, she developed a severe headache associated with lethargy to the point of requiring help with ambulation.  EMS was called and she was taken to the ER at Medical Center.  In the ED, she was noted to be agitated, unable to answer questions or follow commands with periods of decreased responsiveness. She was febrile to 100.8 and admitted to the hospital out of concern for CNS infection. She was started on Rocephin, Vancomycin and Acyclovir. Lumbar puncture was unable to be performed. Routine EEG showed delta brush per report concerning for NMDA encephalitis. She was transferred to Hospital for further evaluation and treatment. Prior to transfer her home buproprion 150 mg, vraylar 3 mg (to moderate aggression per father), dextroamp-amphetamine 30 mg (on and off), disulfiram 250 mg (for lyme per father), lithium 150 mg, naltrexone 50 mg, topiramate 25 mg bid, liraglutide 0.6 daily subcutaneous, zolpidem 12.5 mg, mirtazapine 30 mg, minocycline 100 mg bid were discontinued.      Hospital Course:  On presentation to Hospital, lumbar puncture was performed and showed R6271, W63, G62, P 106. MRI brain with contrast obtained showed diffuse symmetric bilateral white matter signal changes with focal enhancement of the left temporal lobe. Her neurologic examination was very poor with depressed alertness and impaired oropharyngeal protective reflexes. She had recurrent episodes of hypoxia concerning for aspiration or mucus plugging and thus sent to the ICU where she was intubated for acute respiratory failure. Given concern for immune mediated process she completed 5 plasma exchanges while in the ICU. Unable to wean from mechanical ventilation she had tracheostomy and PEG tube placed. Following her plasma exchanges a repeated MRI brain was obtained showing resolution of previously seen enhancement but continued white matter T2 signal abnormalities. Repeated lumbar puncture was performed showing improvement of previously noted lymphocytic pleocytosis. Infectious panels from CSF were unrevealing. Oligoclonal bands were not unique within the intrathecal space. Autoimmune panel including NMDA receptor antibodies were negative. EEG monitoring during admission showed no epileptiform discharges nor previously noted delta brush from sending facility. Following plasma exchange only subtle improvement was noted in neurologic examination and thus empirically she was treated wit IVIG and Corticosteroids. It was the impression of treating teams that patient suffered an inflammatory leukoencephalitis likely related to recently obtained vaccination. Family requested second opinion from another Medical Center. Patient was transferred once bed became available.   Comprehensive Serologic and Spinal Fluid analysis and results at time of transfer  - HIV negative - HSV negative - Syphilis VDRL negative - Meningitis panel negative - heavy metal screen negative - Non-gynecologic cytology increased small lymphocytes present - Cryptococcal CSF negative - West nile AB negative - Toxoplasmosis negative - AFB stain CSF (no smear available), Cx negative - fungus culture negative - CSF gram stain/culture negative - NMO/AQP4-IgG CSFneg - Oligoclonal bands (2) present in serum and CSF (indicative of systemic rather than intra-cerebral synthesis of gammaglobulins) -  MOG-ab CSF neg - JC virus negative - Lyme CSF ab negative - BK virus CSF neg - Paraneoplastic AB CSF negative (w/o IFA cell based assay, unfortunately no LGI-ab or NMDA-ab included in this panel) - NMDA ab serum - negative