Age: 32.0
Sex: F
Vaccine: COVID19
Symptoms: Vaccine breakthrough infection
Clinical narrative: Burning/blistering rash developed abruptly on left arm, chest, lower legs and right arm that has continued to spread to entire body including lips and inside of nose. Numbness in hands and feet. Notes from all medical visits below. 5/17/2021 Walk-In. Patient present with a worsening rash x today.  She received her second Pfizer COVID vaccine on 5/14.  Patient reports a small rash at the vaccine site that evening.  No worsening of rash over the weekend.  Patient denies fevers, HA, ST, dyspnea.  She reports a history of skin sensitivities.  No new soaps, lotions or detergents.  No new medications or supplements.  No itching or pain from rash.  She reports that her symptoms started with small, clear, "bubbles", then turn into flat, excoriated erythema. 5/19/2021 SMHC ER. 32 y.o. woman presenting with a rash.  Patient had her second COVID-19 vaccine on 5-14.  On 5-17 started developing a rash over her left arm at the site of the vaccine.  Started with clear bubbles, that then look excoriated.  She reports that they feel like they are burning.  They have since spread to her chest and her back, her legs, her arms.  She has put a little bit of antibiotic ointment on some of them, but this has not helped. No painful urination.  Does report her eyes and her mouth feel dry. 5/19/2021 Dermatology Pt arrived from the ER admitting to significant fatigue. The burning in her skin has an abrupt onset which wakes her from sleep. She notes that starting Saturday 5/15 she has had intermittent pins and needles in her hands and feet. As of today her right foot is becoming more numb. She also notes the onset of burning at the left inside of her mouth. 5/20/2021 Dermatology. Assessment and Plan: 1. Neoplasm of uncertain behavior of skin. 32F with vesicular - petechial eruption with secondary crusting at trunk and extremities s/p 2nd Pfizer COVID-19 Vaccine on 5/14/21. Vasculitis vs DIC vs Stevens Johnson syndrome/ TENS in pt with symptoms consistent with coronavirus infection despite vaccination. SURGICAL PATHOLOGY TISSUE SPECIMEN; pending. Skin biopsies sent urgently on 5/19/21 for H&E and DIF. Prednisone started 5/19/2021 in ER: 60mg x3 d, 50mg x 3 d, 40mg x3 d, 30mg x3 d, 20mg x3 d, 10mg x 3 d (18 day taper). Out of concern for possible vasculitis compromise of the pt's kidneys I prescribed bleach baths and topical mupirocin oint rather than add systemic antibiotics for secondary infection of lesions. Given the worrisome and worsening presentation, the pt and her husband agree to present to the E.R. They declined transport by ambulance and will go to the E.R. now. Number and Complexity of Problems Addressed. 1 acute or chronic illness or injury that poses a threat to life or bodily function. Mild headache last evening, no blurry vision. Extreme fatigue with effort of getting up and getting dressed Interrupted sleep with persistent burning pains at LEs, pins and needles at hands and feet and worsening blue discoloration at LEs and numbness at 2nd & 3rd rt toes. Has been able to hydrate; urine light yellow. Appetite maintained but no stool since 5/17. Pt removed IV from rt antecubital which had been left by E.R. 5/20/2021 ER. This is a 32 y.o. female  with a rash that initially developed over her injection site from her second COVID vaccine received 6 days ago.  The rash begins as bubbles and then appears excoriated.  Described as burning and have since spread to her chest, back, legs and arms.  She was evaluated yesterday at SMHC ED and Dermatology.  Placed on 60 mg Prednisone and admits that the pain has not really improved.  Sent here today for concern of DIC/Vasculitis/SJS. Patient well appearing, VSS. Will repeat labs, provide 1 L NACL and Oxycodone for pain. Had today's dose of Prednisone. Does have decreased DP pulses, foot mottling and decreased capillary refill.  Will obtain bilateral arterial US. Discussed with Dr. who also evaluated the patient and is in agreement.    Labs improved from yesterday, only mild elevation of D-dimer.  Some protein in her urine. Repeat evaluation after keeping her legs covered reveals normal cap refill less than 2 seconds.  Still mottled and unable to palpate DP pulses bilaterally. 5/21/2021 Assessment. Prescribed Ondansetron Hydrochloride 4 mg For nausea.