Age: 76.0
Sex: M
Vaccine: FLU4, PNC13
Symptoms: Lumbar spinal stenosis, Magnetic resonance imaging brain normal, Magnetic resonance imaging spinal abnormal, Myelitis transverse, Myelopathy
Clinical narrative: November 2019. Back/legs, aching/fatigue commenced early mid-month, as did erratic bowel movements. Culminated with hospitalization on 11/25 after an extended period of constipation and fatigue resulted in a severe bowel attack, walking difficulty and spasmodic body shaking. Initial thought was a paralytic ileum which was subsequently discounted. Discharged on 11/26 and directed to get a colonoscopy.  December 2019. Colonoscopy on 12/5  uneventful, no ileus. Walking/balance/gait continued to deteriorate. Unable to get a neurologist appointment.  January 2020. Saw neurologist on 1/3. He prescribed a brain MRI which demonstrated no signs of MS. He wasn't available to see me again until March 23, 2020. Went to Urgent care clinic on 1/13 and given a prescription for doxycycline to rule out possible Lyme disease as a cause. No positive effect. Saw an osteopath for an EMG test on 1/22 and he indicated the need for neurology treatment and also prescribed a lumbar MRI, which demonstrated no inflammation, just stenosis. Saw a peripheral nerve disease doctor on 1/28 who upon receipt of MRI's of my thoracic region of the spine, referred me to colleague who specialized in spinal disorders.  February 2020. On Feb 5th, after being diagnosed with transverse myelitis, commenced a 5 day steroid infusion. It provided limited, short term relief and then I continued to deteriorate, worse than before the steroid infusion. Doctor consulted with an infectious disease doctor and together they decided to put me on a 3 week infusion of ceftriaxone to take Lyme disease off the table  that started about 2/20. It had no effect on my walking issues and I continued using a walker or wheelchair. I started PT in February in effort to hold on to some muscle strength. Bowel issues continued with extensive periods of constipation followed by explosive movements.  March 2020. Ended my ceftriaxone infusion on 3/10 and diagnosed with Covid on 3/17. All Covid symptoms gone by 3/28, however, body very weak and unable to walk without wheelchair or walker. PT stopped with onset of Covid. Bowel issues continue.  April/May 2020. Doctors unsure what treatment to pursue so I started a second round of 5 day steroids infusion on 5/20. CT scan on 5/22 ruled out cancer as the myelitis cause. Legs very achy, feet, lower legs numb and tingly. Bowel issues continue.  June 2020. The steroids were more effective than the first infusion and I could detect some improvement in my walking, so I was able to move from the wheelchair to the walker and a cane towards the end of June. Knees remained painful, as did feet, which were numb and tingling. Recommenced PT after visiting rehab doctor on 6/15who had xrays taken of knees and hips due to my complaining about soreness. Xrays established nothing more than normal deterioration. Had another thoracic spine MRI on 6/26 which demonstrated that inflammation had abated. Bowel issues continue.  July/August 2020. Continued PT. Slow but steady walking improvement. Balance better but still not stable. Gait, awkward. Using predominantly cane, exclusively in August. Bowel issues continue.  September 2020. MRI on 9/17. Shows inflammation dormant with some residual scarring. Walking slightly better. Continued PT. Knees achy, feet numb/tingly/freezing at night. Bowel issues continue.  October 2020. More stamina, but marginal improvement in balance, gait and discomfort. Knees and feet bothersome. Balance mediocre. PT ended. Bowel issues continue.