Age: 37.0
Sex: F
Vaccine: COVID19
Symptoms: Epstein-Barr virus test positive, Eye movement disorder, Eye pain, Fatigue, Fibrin D dimer normal
Clinical narrative: Thirty minutes after the shot, I started having head pain, fatigue, and chills. The day after the shot, I started having tightness in my chest, sore neck and shoulders, sore jaw, and twitches in my right thumb. I called the Pharmacist to report my symptoms and was told to take Tylenol and Ibuprofen. He also gave me the VSAFE number to call. I called the VSAFE number and all the representative did was email me a link to their website with common side effects from the vaccine. Three days after the shot, my eyes felt sore and were difficult to move. I went to see my Primary Care doctor. I was told that my symptoms were normal, was told to take ibuprofen, and was encouraged to take the second shot. Five days after the shot is when the numbness, tingling, and twitches started in my arms and legs. I had trouble sleeping because of the tremors,. I also had rapid heart rate. Six days after the shot, I saw my eye doctor to have my eyes checked. The eye doctor said my eyes looked fine and to follow-up with my Primary Care doctor. A week after the shot, I went to see a Neurologist who gave me a Depo-Medrol shot and prescribed ten days of Clonazepam (0.5 mg tablet at night) and steroids for the next two weeks. I took a Methylprednisolone 4mg dose pack for the first week, and Prednisone (10 mg) for the second week. The Clonazepam helped me sleep and calmed the tremors. One week and three days after the shot, I started seeing a Cardiologist. After the two rounds of steroids, I was prescribed Cyclobenzaprine (10 mg at night) to help with the head pain. I took Cyclobenzaprine intermittently from 9/2021 to 1/2022. On 10/8/2021, I had an echocardiogram done, and my heart rate was slightly higher than normal. Six weeks after the shot is when the stabbing, burning pain started in my legs, buttocks, and back, and I lost all muscle tone in my body. I had weakness in my legs, and it was hard to walk. I had to get an emergency appointment with the Rheumatologist the Neurologist referred me to. The Rheumatologist prescribed Gabapentin (300 mg x 3 daily). Nine weeks after the shot, I noticed the blotchy look on my skin, and I had also lost 10 pounds. Three months after the shot, I had muscle twitches in my face, and it was hard to move my forehead muscles. On 12/1/2021, I had an EMG nerve conduction study done that the Neurologist ordered. The results were negative however the Neurologist suspected I could have Small Fiber Neuropathy. I also went to physical therapy twice a week for the month of December 2021. The Gabapentin worked for the first two months, but the pain started coming back in January 2022. In February 2022, I saw a new doctor who took my orthostatic vitals, and they were elevated. She suspected I had POTS, and referred me back to the Cardiologist. I went to an Urgent Care on 2/13/2022 because of the pain, and I was referred back to my Rheumatologist. On 3/3/2022, I had a blood test done to see if I had a reactivation of old infections. My Mycoplasma Pneumoniae and EBV levels were high. On 3/23/2022, I did a tilt table test that confirmed I had borderline POTS. It?s been eight months and two weeks, and I still have paresthesia and pain in my legs and left arm, tingling, muscle twitches, fatigue, and rapid heart rate. I?m currently taking anti-inflammatories and vitamins to help with my symptoms.