Age: 31.0
Sex: M
Vaccine: COVID19
Symptoms: Rash, Red blood cell sedimentation rate increased, Red blood cells urine, Scan with contrast abnormal, Skin plaque
Clinical narrative: 4 days prior to admission, patient suddenly noted bipedal edema, pitting in character along with petechial rashes on the bilateral feet. Rashes were non  tender and non  pruritic. No other associated signs and symptoms. No medications taken. No consult done.  3 days prior to admission, bipedal edema persisted and rashes progressed above the knee. The patient experienced joint and muscle pains which were intermittent and migratory. It would occur on the knees or the elbows or on the low back area. No fever noted. No consult done.  1 day prior to admission, symptoms persisted, hence teleconsult was done and was requested the following labs: Urinalysis: yellow, clear, acidic, negative protein and sugar, 0-1RBC, 0-1WBC, 0-1 pus, few epithelial cells Crea 70.72 SGPT 230 (increased) ESR 37 (increased) HBsAg and AntiHBs non-reactive  Before being able to follow up, the patient developed severe generalized abdominal pain, crampy in character, 10/10 on the pain score which would last for a few minutes to hours then will spontaneously resolve. This was not aggravated by food intake.   Few hours prior to the admission, the pain was no longer bearable, hence consult at the ER and subsequent admission.  ROS:  (+) chronic low back pain, work up showed normal results (-) Anosmia, ageusia, lower urinary tract symptoms, BM changes (-) Chest pain, palpitations, orthopnea, edema   Past Medical History: Unremarkable Injected with 1st dose of COVID Vaccine (Moderna) last August 30, 2021  Family History: Unremarkable  Social History: Non-smoker, non-alcoholic beverage drinker, denies illicit drug use Patient is a Pastor. He lives with pregnant wife and 2 toddlers in a studio-type apartment.  Upon arrival at the ER, he was awake, in severe pain Vital Signs: BP 100/80 HR 71 RR 22 Temp: 36.2 O2 sat: 98% at RA Anicteric sclerae, pink palpebral conjunctivae, no CLADS Nondistended neck veins, dry lips and moist oral mucosa Clear breath sounds Normal rate regular rhythm, no murmurs Soft abdomen with normoactive bowel sounds, (+) tenderness on all quadrants more prominent on the right hemiabdomen Full pulses, grade 1 bipedal and bilateral hand edema (+) Multiple, dusky erythematous, well-defined, round non-blanchable papules and plaques on the lower extremities  Course in the Wards:  The patient was admitted as a possible case of COVID Vaccine Induced HSP given the timeline of events. He was referred to the Nephrology, Rheumatology, Gastroenterology, Hematology and Infectious Disease Services. Work up was done. Steroids were started along with pain medications. Due to difficulty of eating due to the feeling of unwellness, patient was started on IV hydration. After initiation of steroids, there was significant decrease in abdominal pain.   On the 1st hospital day, the patient is stable with less abdominal pain. He was referred to the Dermatology service and biopsy of the skin lesions were done. Results are still pending. CT Scan of the whole abdomen with IV contrast was also done and showed gastric and bowel wall edema, irregular mucosal thickening and undue enhancement with fat stranding and adjacent prominent sub centimeter lymph nodes which may be secondary to a non-specific vasculitis. Management was continued.   On the 2nd up to current hospital day, patient subjectively feels better. Edema is resolving along with rashes. Abdominal pain is less and patient has better appetite.   09.30.21 HEMATOLOGY  Hemoglobin 162 hematocrit 46 WBC 5 -10 x 10^9 / L 8.0 Neutrophils 72 lymphocytes 28 Platelets 150    09.30.21 SERUM CHEMISTRY  Sodium 135 Potassium 3.7 Mg  0.64 Ionized Calcium 1.25  Albumin Mass 41  SGOT  41.55 (1.0003x)  SGPT  140.23 (3.5x)  TP  68.53  A  41  G  27.53  Lipase  6.42  Fibrinogen  2.4  09.30.2021 CHEST XRAY: CLEAR ECG: NORMAL SINUS RHYTHM 2D ECHO: 77% EF Normal left ventricular dimensions with adequate contractility and systolic function Normal atria Normal valves Normal left ventricular diastolic function Normal pulmonary artery systolic pressure  WHOLE ABDOMINAL CT SCAN WITH IV CONTRAST Impression: 1. Gastric and bowel wall edema, irregular mucosal thickening and undue enhancement with fat stranding and adjacent prominent sub centimeter lymph nodes, as detailed above. In this patient with a history of bipedal edema and purpuric rashes in both lower extremities, findings may be secondary to a non-specific vasculitis. The possibility of gastric and bowel wall infarct or inflammatory changes cannot be entirely excluded. Direct endoscopic visualization is suggested.  2. Cholecystolithiases with no evidence of cholecystitis during the time of examination. 3. Small undescended left testicle.