Age: 73.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Red blood cell count decreased, Red blood cell sedimentation rate increased, SARS-CoV-2 RNA undetectable, Scrotal swelling, Serum ferritin normal
Clinical narrative: Patient has experienced a series of unexplained immunologic or vasculitis events.  We make this report while the medical diagnostic journey is still underway. June 29, 2021: While on vacation, patient awoke with hives on chest and trunk; self-treated with diphenhydramine 50 mg PO which reduced the rash.  Later that same evening, patient developed urticaria and hives on trunk and arms, and swelling of the lips.  Presented to Emergency Department at Hospital.  Treated with solumedrol 125 mg IV;  famotidine 20 mg IV.  Patient has no history of food or environmental allergies. Has traveled to 50 countries and eaten and drank local foods and bevs.  Discharged from ED with Prednisone taper over 9 days; famotidine 10 mg PO BID. July 16, 2021: Patient developed swelling and redness of the right side of the scrotum. July 18, 2021: Patient with advanced swelling and redness of the right scrotum presented to the Emergency Dept at Hospital.  He was seen by a Urologist.  Scrotal ultrasound revealed a necrotic right testis without Doppler flow or waveform.  Laboratory values included: SARS-COV-2 RNA  Negative. CBC and diff: WBC 11.52;  RBC 3.60, HGB 11.7, HCT 34.8%, MCV 96.7, Lymphoctyes 8.3%, Platelets 189 10*3u/L. ProTime 11.60 sec, INR 1.0, Basic Metabolic Panel unremarkable, but for Calcium 8.2 (ref 8.3-10.3), C-Reactive Protein 78.7 mg/L (reference <10), Lactate dehydrogenase 518 U/L (reference range 313-618 U/L), Tumor markers were drawn and surgery was deferred until markers results would be available. July 21, 2021:  Patient became febrile, with cellulitis of the groin advancing up to the lower abdomen.  Returned to Hospital Emergency Dept.  Treated with IV antibiotics and admitted to the hospital, still pending tumor markers drawn on July 18 which would dictate the surgical approach. Troponin-I:  <0.012 ng/mL, Lactic Acid, serum: 0.8 mmol/L, Basic metabolic panel: unremarkable, Blood cultures: Negative, CBC with diff:  RBC 3.50 x10*6/uL, HGB 11.0 g/dL, HCT 33.3%, MCV 95.1 fL, lymphocytes 11%. Patient baseline has historically low HGB (13) and HCT (38). July 22 ESR: 91 mm/hr (ref 0-25). July 22 SARS-COV-2 RNA: Negative. July 23, 2021:  Patient underwent R orchiectomy which found no tumor, no torsion and no indication for the necrotic testis.  Pathology final anatomic diagnosis:  Non-viable testis with hemorrhage, congestion, hemosiderin-laden macrophages and cystic degeneration. Tumor markers: HCG Tumor Marker QN: <2mIU/Ml (reference <5).  Alpha-1 Fetoprotein:  7.2 ng/mL (reference <6.1)   Discharged to home with pain meds, bowel meds, Prednisone 20 mg QD x 5 days; loratadine 10 mg QD x 7 days. Sept 3, 2021:  Patient was evaluated by a Hematologist, in consideration of vascular issues. Multi labs drawn: ProThrombin Factor II Gene Mutation: Not detected. Factor V Leiden: Variant not detected. ESR:  37 mm/hr (range 0-25). Repeat 29. Folate & B12: WNL, CBC: RBC 3.86, HGB 12.0, HCT 36.8%, MCV 95.3 fL. Lymphocytes 18%. Diff within reference ranges. Ferritin 221, Iron and TIBC within reference range. C Reactive Protein: <5.0 mg/L. D-dimer <230.0 D-DU/ ng/mL, Lupus Hexagonal Phase: Negative.  Lupus Anticoagulant:  Not detected. ProTime 11.20 seconds.  INR 1.0, Anti-cardiolipin AB IgG not detected, Anti-Cardiolipin AB IgM not detected. Protein C Activity: 191% (ref range 70-180%). Protein S Activity: 99% (ref range 70-150%). Antithrombin III: 109% (ref range 80-135%). Sept. 25, 2021:  Patient awoke with swollen lips, asymmetrical with more pronounced swelling on the Left side, with some facial swelling. Also noted swelling of left lower extremity. No hx of edema, PVD, CHF.  Presented to Hospital ED for evaluation. Labs: Basic Metabolic Panel: unremarkable, within reference range. CBC with diff: WBC 5.62;  RBC 4.22, HGB 13.2 HCT 40.2%, MCV 95.3 (consistent w/ patient hx).  Eosinophils: 5.9% 9 (0-5%). C3 Complement:  111 mg/dL (82-185).  C4 Complement: 29 mg/dL (15-53). Ultrasound Left Lower Extremity: No DVT. Etiology of symptoms remains unclear.  Discharged from ED to home on 9/25/2021 with prednisone, loratadine, famotidine and EpiPen. Oct. 29, 2021: Patient has appt with allergy & immunology specialist.