Age: 81.0
Sex: M
Vaccine: FLUA3
Symptoms: Antinuclear antibody positive, Back pain, Biopsy bone normal, Bladder catheterisation, Blood culture negative
Clinical narrative: Patient received 2018-2019 influenza vaccine on 10/2/18 at primary care provider (PCP) during routine visit. Patient was well on day of vaccination and visit was a follow up on chronic conditions. On 10/03/18, patient reports having achy pain across his shoulders, neck, and upper back. Progressively over multiple days, the pain has spread throughout his body & feels like a "tooth ache" all over. Patient initially presented to the hospital on 10/13/18. Workup included chest x-ray, (unremarkable), lumbar spine Xray (degenerative changes), and lumbar spine MRI (Posterior disc bulge noted at T12-L1, L4-L5 and L5-S1 levels and hematopoietic changes). Cardiac workup, including EKG and troponins, was negative. Pt was diagnosed with Acute bilateral low back pain without sciatica was treated with physical therapy and pain medication. Pt's condition remained stable with treatment. On day one of admission patient was discharged to home with orders for home PT. Other chronic conditions were either stable with home medications or non-contributory during this hospitalization. On 10/18/18, patient re-presented to PCP office with continued pain, reduced mobility, weight loss, and inability to eat. Patient was directly admitted to the hospital for additional work up. Neurology, hematology, infectious disease and family medicine providers participated in care of this patient. Testing done on second admission included bone bx (negative), lumbar puncture (slightly elevated protein otherwise normal, culture negative), EEG (no seizure activity). Patient had urinary retention requiring a catheter. Patient had poorly coordinated swallow and failed numerous swallow studies with speech and language pathology. Infectious disease workup (blood and urine cultures, fungal panel, HIV, hepatitis, respiratory viral panel) was negative. Positive findings included Sed rate of 56, CRP of 19.9, positive ANA titer >1:640 speckled (testing done 10/26/18). Neurology and ID recommended temporal artery biopsy to confirm diagnosis but after discussion with anesthesia determined that patient was not strong enough to tolerate the procedure under general anesthesia. Patient was started on high dose steroids to empirically treat for temporal arteritis. Hospital Treatment Course with steroids included: prednisone 20 mg tablet 1 tablet daily (10/18/18-10/24/18), methylprednisolone 125 mg IV four times daily for a total of 12 doses (10/28/18-10/31/18), prednisone 60 mg tablet 1 tablet daily (10/31/18-11/8/18); Patient was discharged to a rehabilitation center with PEG tube for nutrition on 11/8/18. Foley catheter was removed prior to discharge. Patient had improved range of motion but limited strength. Patient was unable to pass a swallow test and thus received a PEG tube for nutrition. He tolerated tube feeds well. Was able to void after removal of the catheter. Plan to continue long taper of prednisone after hospital discharge (60mg x 2 weeks, then 50mg x 2 weeks, then if improving and ESR and CRP return to normal, taper by 5mg every two weeks to 20 mg daily, then by 2.5 every two weeks until down to 10mg, and then tapering by roughly 1mg per month for the next 6-12 months depending on improvement in disease course).