Age: 80.0
Sex: F
Vaccine: COVID19
Symptoms: Headache, Laboratory test normal, Magnetic resonance imaging head normal, Metabolic function test normal, Red blood cell sedimentation rate normal
Clinical narrative: I received two doses of the Moderna Vaccine: #1: 02/12/2021 Pharmacy COVID19 (Moderna) Lot#031M20A IM Left Amr in AM #2: 03/12/2021 Pharmacy listed as above in items 15, 16 and 17. I am a healthy 81 year old woman who, prior to February 2021, had no active medical problems, was taking no medication and was exercising regularly. My weight is normal and I have no history of hypertension or headaches and I see my primary care doctor yearly, if that. I received Vaccination for Covid-19 with injection of Moderna Vaccine on 2/12/21 and 3/12/21. Subsequent to the first injection, I required an overnight hospitalization at the hospital (2/18/21) for altered mental status felt to be due to elevated blood pressure (SBP-210 on arrival at ED). During hospitalization, all labs including Covid-19 PCR and CT/MRI of my brain were essentially normal and are attached. By discharge, my blood pressure had normalized without medication but remained very sensitive to any caffeine. Normally my blood pressure is 120-135/70-80 but, with intake of small amounts of caffeine after hospitalization, my systolic blood pressure might increase by 30 points. At this time of this writing, my blood pressure has returned to its usual level, requiring no medication and is no longer as sensitive to caffeine. Then subsequent to the 2nd Moderna vaccine injection on 3/12/21, I developed new onset headaches on 3/14/21. This head pain has always been in the same place; a circular area above my left eye at the hairline and near the beginning, this aread developed subcutaneous tissue loss or a sunken area that has grown to about the size of a nickel coin. The pains were very severe at the beginning and occurred almost exclusively at night, lasting 8-10 hours continuously, and were not accompanied by any other symptoms. There have been no muscle or joint pains, fatigue, skin redness or swelling, uri symptoms, visual disturbances or sensitivity to light or noise. The head pain has responded to prn local ice pads, tapering prednisone (beginning at 20mg qam) and gabapentin. Over time, the head pains have lessened in severity and frequency. Multiple efforts to taper off of prednisone have results in recurrence of the headaches and I'm now taking 1mg qam. Then on 11/16/21, I noticed a new linear indentation in my forehead which developed rather rapidly (picture attached), extending from the original area of pain down to my left medial eyebrow, basically following the path of the supratrochlear nerve. This looks similar to a process called linear scleroderma (en coup de sabre) but a biopsy by my local dermatologist was negative for an active process. There was never any redness, swelling, itching or pain in the area of this skin change which has not improved. Now, I'm presently headache free on prednisone 1mg qam and gabapentin. I'm stared to take a booster shot for Covid-19 and this is very troubling to me. I would like to know your opinion about my taking a booster shot and whether similar reports of transient unstable blood pressure, head pains and skin changes such as these have been received and are related to the Moderna vaccine. I would like to be able to take Covid-19 booster shots in the future.    Medical doctors I've seen for these problems include: 5/12/21: MD DX: Headache 6/8/21: MD Dx: Hypneic Headache TX: Intranasal lidocaine, prednisone. 8/23/21: DO Dx: Headache Tx: Gabapentin 10/7/21: MD Dx: Nummular headache Tx: Local steroid/lidocaine injection 1/3/22: MD Dx: R/O linear scleroderma