Age: 29.0
Sex: F
Vaccine: COVID19
Symptoms: Irritable bowel syndrome, Laboratory test, Lymphocyte count, Magnetic resonance imaging head normal, Magnetic resonance imaging spinal normal
Clinical narrative: ? 04/30/2021: 2nd Covid Vaccine ? 05/01/2021: Woke up in the middle of the night after receiving the shot due to extreme body-wide pain. It felt like all the muscles in my body were spasming and my skin was hot and puffy. Almost woke my parents to take me to the emergency room but tried an Epsom salt bath first. It calmed the muscles a little and brought the pain down to about a level 8 (where I could barely move but at least I could think over the pain). The next month brought swelling in my legs and arms as well as muscle spasms. Every time I tried to go to work I would have intense pain and my skin would get hot and inflamed. ? 05/10/2021: Saw a primary care doctor about pain after the shot and he prescribed 20mg Prednisone ? 05/12/2021: Went to primary care doctor to have blood work-up after not recovering from muscle pain, back pain, and migraines from shot.  ? 05/13/2021: Saw primary care doctor to review blood work. The blood test did not reveal anything significant. I mentioned that I was in a lot of pain, could barely lift things at work, and was having intense migraines. She put me on Tramadol HCL 50 mg for continued pain. However, the tramadol did not relieve the pain. It only made me feel drowsy and a little loopy.  ? 05/19/2021: Saw my neurologist. He stated that the following issues were addressed: muscle pain. He referred me to go see my rheumatologist. He prescribed me cyclobenzaprine for muscle pain and duloxetine for neuropathy and muscle pain.  ? 05/20/2021: Visited primary care doctor again due to not feeling better after completing steroid pack. She prescribed Meloxicam 15mg and Tizanidine HCL 4mg. ? 05/22/2021: Woke up and had very blurry vision. Tried to get in touch with primary care doctor to see whether or not I should go to the emergency room. I have not been able to drive at all since this occurred.  ? 05/24/2021: Primary care doctor told me to go to the emergency room after losing my vision. They had me stay overnight for observation and tests. They did blood-work, brain ct, and brain MRIs with and without contrast. They couldn?t find anything in the radiology tests to explain my pain and loss of vision. When I first arrived, they found I was hypoglycemic. It took 12 hours before my blood sugar rose enough and then I was hyperglycemic. The following things were flagged in my blood work: glucose, AB CD3 T Cell, CD-4 T Helper, AB CD4 T Cell, CD8 T Suppress, H/S Ratio, CO2 Level, Glucose Level, WBC, Segmented Neutrophils, Lymphocytes, Monocytes, and NEUT #.  ? 05/25/2021: Saw a retinal specialist in emergency room. He recommended I come see him in his office so that he could do proper tests on my eyes.  ? I became unable to read, work on the computer, look at bright screens, watch action movies, look at flashing lights, etc. These things started causing extreme migraines.  ? 05/26/2021: Saw my retinal specialist in his office. He performed the following tests: SCODI (OCT)- optic nerve and retina, Fundus Photos, Fluorescein Angiography, Fundus Autofluorescence, and OCT Macula. He diagnosed me with disseminated chorioretinitis, Posterior Pole and Posterior Vitreous Detachment. He prescribed Ketorolac 0.5% and Cyclopentolate 1%. Due to this I was unable to put in my contacts and wearing my glasses caused migraines. So I saw a very blurry world for 6 weeks.  ? 05/26/2021: Saw my neurologist after hospital visit. He didn?t know what was causing my symptoms and referred me to rheumatologist.  ? 05/27/2021: Saw my rheumatologist. She prescribed colchicine for muscle and joint pain. She referred me to a pain management doctor.  ? 06/02/2021: Saw my retina specialist for a follow- up. He performed SCODI (OCT) procedure on my retina.  ? 06/10/2021: Visited primary care doctor again after still having extreme muscle pain, inflammation, migraines, blurry vision, and hot spots on my chest, arms, and back. ? At about this time, I started having an extreme burning sensation in my brain. It did not go away for several months and would get worse if I tried to think or concentrate. It would get so bad by the end of the day that I would be crying and gritting my teeth because of the pain. My emotions were also affected. I started crying a lot more easily.  ? 06/30/2021: Visited my pain management doctor. She stated that the following issues were addressed: Fibromyalgia, neuropathic pain, discogenic thoracic pain, and memory loss due to medical condition. She prescribed Memantine and advised that I get a MRI on the lumbar and thoracic parts of my back due to ongoing pain and to rule out any spinal damage.  ? 07/07/2021: Saw my retina specialist. He performed a SCODI (OCT) procedure on my retina, fluorescein angiography, and fundus photos. He said that the chorioretinitis looked a lot better and was just about healed. Because I still had blurry vision even though the swelling had gone down, he stated that it sounded like my symptoms were nerve related and I should go to a neuro-muscular doctor.  ? 08/03/2021: Visited primary care doctor to discuss continued burning sensation in my head and pain in back and muscles. He advised me to see a different neurologist. ? 08/05/2021: Visited my pain management doctor. She stated that the following issues were addressed: Neuropathic pain, Disease of white blood cells, and Brain fog. She prescribed: hydroxyzine for insomnia, ketorolac for pain management, and methylprednisolone for ongoing pain. ? 08/09/2021: Saw a new neurologist. She said that she would look over my chart and let me know what to do on a follow-up appointment.  ? 09/08/2021: Visited my pain management doctor. She stated that the following issues were addressed: Positive ANA (antinuclear antibody), Fibromyalgia, Irritable bowel syndrome with constipation, Disease of white blood cells, Neuropathic pain, Multisystem inflammatory syndrome in adult (MIS-A) associated with COVID-19 vaccine, Chronic headache with new features. She advised that I go see a neuromuscular doctor.  ? 09/13/2021: Saw neurologist for follow-up. She said she had no idea what was causing my symptoms and to go see a specialist.  ? 09/27/2021: Visited primary care doctor to discuss ongoing pain, pins and needles tingling sensations all over my body, and pain in my back. Increased gabapentin prescription. My doctor suggested that I try the COVID center downtown. He also wanted me to see a rheumatology specialist. He says he thinks not only does it sound like I have an immune system problem, it also sounds like my nerves are overworking. ? 10/06/2021: Saw my retinal specialist. Still having blurry vision, difficulty reading, can?t look at computer screens, and get migraines from bright colors and quick movements. I also am still having floaters in my eyes and difficulty seeing my periphery. He still recommended seeing a neuro-muscular doctor because my symptoms could have to do with neuro-overdrive. ? At about this time, I started getting more and more stabbing migraines and burning in my head each day.  ? 10/13/2021: Saw an infectious diseases doctor. He stated that the following issues were addressed: burning sensation, joint pain, anxiety problem, intolerant of cold, skin irritation, and difficulty falling or staying asleep. He referred me to a medical counselor and a rheumatologist. ? The burning in my brain sensation and hot spots started lessening, but transferred to pins and needles pain in my arms and hands. No medication has ever helped with my pain except in very minute amounts.  ? 11/02/2021: Visited primary care doctor to discuss ongoing pain in back, muscles, paresthesia body-wide ( but especially in hands and arms), and insomnia due to pain and restlessness in brain. He increased my gabapentin prescription for nerve pain and prescribed Zolpidem Tart ER 12.5mg Tablet for pain-induced insomnia. ? 11/19/2021: Saw a specialty rheumatologist downtown. She looked at my chart and didn?t think my symptoms were rheumatological. She thought I had small nerve neuropathy and wanted me to get a skin biopsy and EMG with a neuro-muscular doctor.  ? 12/07/2021: Visited my Pain Management doctor. She stated that the following issues were addressed: Multisystem inflammatory syndrome in adult (MIS-A) associated with COVID-19 vaccine, Neuropathic pain, Disease of white blood cells, and Fibromyalgia. She prescribed amitriptyline for my insomnia caused by pain and brain issues. Also prescribed Hydrocodone-acetaminophen for pain.  ? 12/09/2021: Saw a medical counselor about my medications. She stated that the following issues were addressed: joint pain, anxiety problem, cold intolerance, skin irritation, burning sensation, and difficulty falling or staying asleep. She prescribed propranolol for anxiety.   ? At about this time my joints started swelling and the pins and needles feeling started to make it very difficult for me to use my hands. It hurts to open jars, wash my face, scrub my hair, use knives and forks, etc. Some days the food and cutlery is so heavy I have to get someone else to feed me.  ? At about this time the pins and needles feeling started spreading from my hands and arms to the rest of my body especially if I had tried to move around or pick anything up. Still unable to sit without a lot of cushioning. Even then sitting more than about 30 minutes causes extreme pain and muscle spasms.  ? 12/27/2021: Visited a neuromuscular doctor. She stated that the following issues were addressed: Nerve disorder, Idiopathic progressive neuropathy, Problem with function of peripheral nerve, Neuropathic pain, Difficulty swallowing, Migraines, and Neuromuscular junction disorder. She advised getting an EMG, having skin biopsies taken, and getting some blood work done. She prescribed tizanidine for my back spasms.  ? 01/06/2022: Saw my medical counselor for a follow up.  ? 01/19/2022: Saw my infectious diseases doctor for a follow up. He stated that the following issues were addressed: cough, COVID-19, breathlessness on exertion, head congestion, and pain. He recommended that I continue seeing my neuro-muscular doctor. ? 01/23?/2022: My neuromuscular doctor called and informed me that my blood work showed that my positive ANA was very high, my Vitamin B6 was very high, and my Vitamin B12 was very low. She advised me to start taking 1000mcg of B12 daily. I haven?t felt any different since I started taking the B12. She also increased my gabapentin prescription to the highest dose.  ? About this time I started getting massive hot flashes on my torso, arms, and hands. However my lower legs and feet will still be freezing cold. So my torso will be sweating, but I will still need to put a heating pad on my feet.  ? Depending how much I do during the day affects how much pain I will be in later. We try to have me in a wheelchair whenever possible but bright light, talking, and sitting all hurt and cause high heat and inflammation later on. Even just going to the doctor causes severe pain for several days.  ? 01/26/2022: Visited my Pain Management doctor. She stated that the following issues were addressed: neuropathic pain, Fibromyalgia, Multisystem inflammatory syndrome in adult (MIS-A) associated with COVID-19, positive ANA (antinuclear antibody), chronic headache with new features, Irritable bowel syndrome with constipation, disease of white blood cells. She prescribed oxycodone-acetaminophen for ongoing pain. She also increased my amitriptyline medication due to ongoing pain-induced insomnia.  ? 02/15/2022: Visited primary care doctor and discussed disability forms, insomnia, paresthesia, ongoing pain, and muscle weakness. He referred me to a different neurologist and asked me to go to a physical therapist to do a functionality test to determine level of disability.  ? 02/22/2022: Visited my neuromuscular doctor to have the EMG and skin Biopsies done.  ? 03/16/2022: Was advised by my neuromuscular doctor that the skin biopsies did not reveal anything and the EMG showed that a nerve on my lower back was possibly pinched.  ? At about this time my hot flashes moved up to include my neck, head, and scalp. I have developed a heat rash on my lower neck/ upper chest region. It is very hard to cool off. I try to put ice pack on my stomach, chest, and head and even then it still takes a while to cool down. My feet will still be very cold.  ? 03/30/2022: Visited my Pain Management doctor. She stated that the following issues were addressed: Multisystem inflammatory syndrome in adult5 (MIS-A) associated with COVID-19 vaccine, Neuropathic pain, other chronic pain, Chronic bilateral thoracic back pain, Muscle spasm. She prescribed Methocarbomal for daytime muscle spasm relief.  ? 04/01/2022: Had a functionality test performed to determine my level of disability as required by my primary care doctor. ? 4/06/2022: Saw my retinal specialist. He recommended that I go see another rheumatologist. ? 04/19/2022: Saw a new neuromuscular doctor. She stated that the following issues were addressed: nerve disorder, malnutrition, calorie, vitamin B12 deficiency, headache after vaccination, stammer. She advised that I get another blood work-up, see a movement specialist, and see another neuro-muscular doctor and get autonomic testing. She also prescribed B12 shots.  ? 4/21/2022: Saw a new rheumatologist. He stated that he did not believe that my symptoms are rheumatological. He believes that my symptoms point to something neurological. He recommended that I go see doctors at academic institutions such as Clinics. Suggested I may have pernicious anemia where I cannot absorb B12. ? I continue to see new doctors and have new tests but still have no diagnosis.