Age: 38.0
Sex: M
Vaccine: COVID19
Symptoms: Laboratory test normal, Malaise, Metabolic function test, Muscle spasms, Myalgia
Clinical narrative: Initially I remember, body aches, headache, low grade fever. It was really severe the first few days but I was sick for about 10 days. As time went on, I got better and better. I got the vaccine on 12/08/2021. 10 days after finally getting better, 12/18/2021 I was going on vacation and in January when I went back to work, I noticed an increase in muscle pain. Before Initially I remember, body aches, headache, low grade fever. It was really severe the first few days but I was sick for about 10 days. As time went on, I got better and better. I got the vaccine on 12/08/2021. 10 days after finally getting better, 12/18/2021 I was going on vacation and in January when I went back to work, I noticed an increase in muscle pain. Before I had cramping in my legs and it would come and go, but all of a sudden, my lower back was hurting, and I had tender points all over my body. Normally if you're like swimming and you're dehydrated, it's like an entire muscle, but with these tender points, if you press them, they feel like a cramp. I have them all over my body, back, legs, abdomen, even in my feet. My left foot, big toe on the right half of my big toe started to go numb. A few weeks later, the bottoms of my feet began being painful and maybe numb. It's hard to tell because there's no sensations. I noticed this feeling while in the shower, it's like numb without pins and needles. I went to my PCP on 02/01/2022 and my doctor sent me to the Orthopedic Foot & Ankle Surgeon. He did a lot of x-rays on my feet and touched my feet and asked if they hurt anywhere. I noted the places he touched didn't hurt. He asked why I was there if my feet didn't hurt, but I noted that they did hurt. He said it was something else, and he noted that I didn't have arthritis. The physical therapy was happening during this time as well. Was doing physical therapy January, February, March and April for the tender points. It was helping so some spots that were painful, they were able to fix with fascial counterstain. Last week of February, I visited a technician of the technique, and he was able to release something in my back that made my foot no longer numb (left foot, big toe, right side of toe). He did something to my lower back since there was a possible restriction there, so toe is no longer numb. Still had pain everywhere else so I went back to my PCP on March 30, 2022. She ordered a large number of tests. She's still concerned, did a bunch of tests. Comprehensive metabolic panel: total bilirubin 1.3mg per dL, 0.2-1.2 reference; ANA screen-came back negative, she did specific antibodies screens, and one came back positive-actin smooth muscle antibody IGG 39iu, reference range is less than 20. Everything else came back negative. Did over 160 blood tests. That one came back positive and everything else came back negative. Smooth muscle IGG 75% of patients with this elevated level have autoimmune hepatitis type 1. I'm scheduled with a hematologist, but they won't be able to see me until June 2022. Because I had a weird thing with my toe that released with my back, my PCP wanted me to see an orthopedic spine specialist and I will see them sometime in mid-May. Also note more fatigue and tiredness throughout day. Also note tender points, if slept on, wake me up at night. Waiting on future appointments to see what the problem could, unsure at this time. Clinic 01/24/2022: Visit with nurse practitioner, prescribed ibuprofen. Addressed left foot pain. PCP 02/01/2022: Referred to foot specialist, picture of my feet taken, pulse was 101.