Age: 59.0
Sex: M
Vaccine: TDAP, TDAP
Symptoms: Back pain, Blood count normal, Blood creatine phosphokinase abnormal, Blood urea nitrogen/creatinine ratio, C-reactive protein increased
Clinical narrative: 7-24-17 Patient saw Dr. for consultation for a long term carpal tunnel syndrome on left hand. Dr. gave him a referral for a neurologist to have an EMG done on hand, and a referral to a hand surgeon for surgery. Also, Dr. set up Physical Therapy to work on hand. At that time, it was noted by Dr.'s nurse, that patient was long overdue for a tetanus vaccine, so patient had the vaccine administered at the pharmacy after his Dr. appointment. Patient's weight 172lb 12.8oz. 7-25-17 Patient noted, during morning hours, how unusually sore his left shoulder was, at vaccine site. 7-26-17 Patient noted that his shoulder/vaccine site, was still unusually sore. 7-27-17 - Upon waking, patient's shoulders, both sore and painful, extending down both arms. Shoulder to arms-stiffness and painful. 7-28-17 - Patient noticed back was stiff, with soreness extending to hips and legs. All over body weakness, he felt pain moving throughout extremities. Patient stated "I am feeling worse than yesterday, I don't know if I can celebrate my 60th birthday party. We might have to cancel it." Note: Patient was looking forward to his 60th birthday party. We had many guests invited. He had to be feeling very bad to even suggest canceling. 7-29-17 Patient began taking 500 mg. TYLENOL every 4 hours, 600 mg. ibuprofen every 4 hours, alternately, to manage pain and immobility. Patient was having difficulty rising from chair, walking and eating. 7-30-17 - continuing TYLENOL and ibuprofen alternately. Pain increasing. 7-31-17 immobility and pain increase from previous day. Continues, TYLENOL and ADVIL. 8-1-17 immobility and pain increase. Continues TYLENOL and ibuprofen alternately. 8-2-17 Appointment at Neurology for EMG. Waited for close parking spot at clinic because walking is difficult. Also started Physical therapy at Chiropractic for carpal tunnel relief. 8-4-17 Increased immobility. Patient needs wife to help get out of bed, go to the bathroom, shower. Cannot go outside to walk or walk dogs. Increased weakness. Continues TYLENOL/ibuprofen. 8-6-17 Increased pain. Considered Emergency Room visit. Decided to wait til 8-7. 8-7-17 Seen by Dr. Tired and fatigued. Pain in shoulders, elbows, wrists, hips, legs. weight 169 lbs. (loss), C-Reactive protein 5.8, Sedimentation rate 52. Dr. thought serum sickness or possible Guillain-Barre syndrome. Started prednisone steroid burst 20mg. x 3x a day for 4 days. 20mg for 4 days after that. Patient has increased immobility. 8-8-17 Seen by Dr. in Clinic, for carpal tunnel release surgery consultation. Dr. noted patient's problems with tetanus vaccine, and said patient could not be on prednisone before surgery. He would need to taper off. Dr. thought it would be best to have surgery ASAP, or patient may lose use of hand, as carpal tunnel was so progressed. 8-9-17 Seen by Dr. for pre-op. physical for carpal tunnel surgery, which is scheduled for 8-18-17. Continues on prednisone, will taper off, for surgery. Continues in extreme pain. Weight down to 168 lbs. 8-12-17 Patient went to urgent care for pain, increased urinary problems. BP 138/76, weight 165 lbs. 9.6oz. On prednisone taper. Pain/numbness increasing. Seen by Dr. ALT 91.00, AST 43, BUN/CREAT 22. Liver counts rising. 8-17-17 Increasing pain and immobility. Patient was seen by Dr. (other doctor out of town). Follow up from urgent care. Tapered to 10mg a day prednisone. Continues TYLENOL and ibuprofen alternately, daily. Severe weakness, fatigue, pain in arms, back, hips, legs, knees, neck and jaw pain. Dr. advises against hand surgery. With careful thought, patient and wife, decide to proceed with carpal tunnel release surgery, as the adverse reaction to the tetanus shot may continue for 1 year, plus. Weight 167 lbs. 12.8oz., liver counts: ALT 139, AST 70, Dr. refers patient to be seen by internal medicine Dr., following week. 8-18-17 - Carpal tunnel surgery. Dr. told patient that he may begin back on prednisone in a day or so. 8-22-17 Patient seen by internal medicine. Weight 168lbs., Sed rate 84, CRP 12.30, ALT 140, CK-Abnormal. Started prednisone 20 mg (60mg)-3x a day. Internal medicine Dr. had patient admitted to Hospital. At Hospital, patient was seen by several doctors. All doctor reports were inaccurate. They did not listen well. They had the wrong dates listed for tetanus shot, symptoms and timeline. One doctor states that vaccine was early July, 2017, while another doctor states that it was in August, 2017. The doctors that patient was seen by, did not acknowledge his symptoms, and misunderstood his pain. Weight 165lb. 165 lbs. 14.4 oz., ALT 140, AST 70, CRP 10.38, Sed. rate 94. 8-24-17 - Released from Hospital, needs wheelchair. On prednisone. 8-29-17 - seen by Dr. - post hand surgery check. Also seen by Dr., Rheumatology. She switched him to Methylprednisolone 24 mg. x 2 a day. 8-31-17 Had CT scan - chest/abdomen/pelvis - check for cancer. 9-5-17 Seen by Dr. 9-7-17 had ultrasound-neck/head? - continues Methylprednisolone 20mg. x 2 daily. 9-20-17 - Started 16 mg. x 2 day dose of methylprednisolone. 9-28-17 Methylprednisolone 12mg x 2 day dose. Went to Emergency Room for heart irregularity. Pounding heart and irregular beats/rhythm. 10-9-17 Methylprednisolone 12 mg. x 2 a day. Seen by Dr. at Cardiology Clinic - intermittent palpitations. Was given Holter monitor. Rest of 2017 from Oct-Dec.: Continues on slow methylprednisolone taper. Increase of muscle loss, fatigue, weakness. 2-7-18 Seen by Dr., Holter monitor-again. 2-8-18 Seen by Dr. 10 mg. methylprednisolone a day. Refers to another hospital. 3-12-18 See by Dr. - neurology at hospital. 6-7-18 Clinic work up at Clinic as referred by Dr. Seen by Internal Medicine, Rheumatology, Neurology. Dates of appoints at Clinic: 6-7-18, 6-11-18, 6-12-18, 6-13-18. Neurology says this is a Rheumatology issue. Rheumatology says that patient has a Neurology issue. Internal Medicine says it is an unknown autoimmune disorder, caused by tetanus shot. Blood counts all look normal, with use of steroids. Internal Medicine believes this could be Rheumatology and Neurology at same time. 6-14-18 - On my way home from Clinic. Totally pissed off. NO ANSWERS. Doctors are not helpful. They cannot diagnose. They have not seen this before. Patient decides to stop methylprednisolone completely, with no taper. 6-15-18 Symptoms returning. 6-16-18 pain increasing. 6-17-18 - Increased pain, discomfort. Hardly able to tolerate our seven grown children, with spouses, visiting during the day and eight grandchildren. 6-18-18 pain, inflammation, fatigue, weakness, increase daily. Can hardly tolerate pain. Noted involuntary muscle twitching. 6-22-18- Return to Clinic for "wrap up" and treatment plan, with Rheumatologist. Doctor is clearly upset with patient, discontinuing methylprednisolone. Dr. stated that he would never diagnose anyone with an injury to the tetanus shot, because the tetanus shot has saved millions of lives. Dr. did more blood work and CRP on rise as well as Sedimentation Rate. Patient still has condition, which was being suppressed by steroid use. Dr. wanted patient to start back on Methylprednisolone again - 2 pills (8mg) and start methotrexate 5 pills (12.5mg) once a week. 6-23-18 to present 1-23-19. Continues on methylprednisolone 4 mg, methotrexate 12.5 mg. a week. 11-1-18 - seen by Dr. at Clinic - switched patient to injection of Methotrexate .5 ml shot (12.5mg). Dr. will retire. He said there is nothing else he can do for patient. Methotrexate is not showing any improvement on condition. Dr. states on 12-4-18 that condition may be permanent and life long. 1-23-19 Patient continues to be fatigued, and weak. Unable to do much physical activity. Depressed mood. Involuntary muscle twitching/movements continue.