Age: 47.0
Sex: M
Vaccine: COVID19
Symptoms: CSF protein increased, CSF red blood cell count, CSF virus no organisms observed, CSF white blood cell count increased, Ceruloplasmin
Clinical narrative: Encephalomyelitis: May 17th, 3 weeks after receiving his Johnson and Johnson COVID vaccine, when he developed two areas of back pain in his mid-scapular and lower back region that felt like typical back pain for him. By late May, he had developed a banding sensation around his abdomen from his lower ribs to just below his umbilicus. He was seen in the ED where serum Lyme serologies were sent and returned positive, so he was started on a 21 day course of doxycycline. However, his symptoms continued to worsen until he developed photosensitivity and sudden horizontal binocular diplopia on June 9th. He was initially evaluated at Hospital, had an LP which reportedly showed elevated WBCs and elevated protein, and was transitioned to ceftriaxone x 28 days. Approximately 1 to 1.5 weeks into this treatment, his double vision resolved.   However, in early July, patient noticed he was having numbness in his feet, especially his left foot. 2 weeks after ceftriaxone: trouble with walking. This worsened and then became associated with imbalance. He also had worsening of the banding sensation and developed intermittent episodes of fecal incontinence, urinary incontinence, urinary hesitancy, and urinary urgency. More recently his numbness in his legs has worsened, and he has developed numbness in his fingertips bilaterally and Lhermitte's phenomenon when he flexes his head. He had an MRI done at an outside facility yesterday which was concerning for transverse myelitis, so his outpatient neurologist referred him to the ED for further evaluation.     He was admitted to the Neurology Service on 7/22/2021 and discharged on 7/27/2021. Initially on exam, mental status, language, and cranial nerves were normal. Motor exam was notable only for hip flexors 4/5 bilaterally. Reflexes were 3+ in the bilateral upper extremities and bilateral lower extremities. Hoffman's was negative bilaterally but crossed-adductor spread was present bilaterally. Toes were upgoing bilaterally. On sensory exam, there was decreased cold sensation to the proximal forearms bilaterally and in the left lower extremity to above the knee. Temperature sensation was normal in the right lower extremity. Vibration was absent at the left great toe, 1-2 seconds at the right great toe, and 4-6 seconds at the ankles and knees bilaterally. Gait was wide-based and ataxic.    MRI brain was unremarkable. MRI C-spine showed two longitudinally extensive lesions in the high cervical and lower cervical/upper thoracic region with patchy enhancement and some edema of the cord, which was concerning for transverse myelitis of inflammatory or infectious etiology, such as post-vaccination myelitis vs primary autoimmune/demyelinating disorder. Serum AQP4 and MOG Abs were negative. CSF was notable for WBC [9,5], RBC 0, glucose 71, protein 75.8, IgG 5.47, and albumin 62.9. There were no oligoclonal IgG bands present in CSF or corresponding serum sample. CSF VZV, HSV, EBV, and bacterial culture were negative, with CSF T.pallidum VDRL Ab, lyme Ab, and fungal culture resulted NEGATIVE Myelopathy labs, including ceruloplasmin, copper, VitB12, MMA, homocysteine, ESR, CRP, ANA, other than Zinc which was mildly low at 52.   He was started on IV MP 1000 mg (course 5 days), improvement noted after first dose. Lyrica 75mg BID was started due to abdominal pain, that is possibly neuropathic. He has been improving since and will need follow up outpatient. After 4 doses of the IV steroid form, it was determined that he has significantly improved, and would be safe to complete his 5th dose in oral form at home, followed by a steroid taper over 6 weeks, starting with prednisone 60mg, with a decrease in increments of 10mg per week.  - After discharge he used the walker for balance during 3 weeks. Right now walks independently.  - He reports he is 90% of his baseline: continues to have numbness, the balance is not great, although he denies falls. More recently he has developed a  Lhermitte's: upon bending his neck he reports shock like sensation down his spine and arms.  - Bladder function is also improving, no urgency or incontinence anymore. Bowels are ok as well.  - While decreasing the dose of steroids, symptoms have remained stable.  -No current plan of PT.    The plan was to update the MRIs, repeat both AQP4/MOG testing and Adenovirus antibodies.    We reviewed Spinal MRI 09/2021: at that time the Lhermitte's was still present, the banding sensation in his knees and balance continued to be unchanged, but overall he felt better. Complete spine MRI still displayed multiple areas of enhancement although decreased since last MRI in 07/2021.  Prednisone: finished 09/09/2021. We decided to order a second round of high steroids (IVMP) and continue prednisone 50mg after that: taper 10mg /week. Infusion was started on 09/22/2021. -- 09/27/2021 followed by a 10mg/week taper. Today is the last day on 40mg.     Interestingly adenovirus antibodies came back positive: 1:64.  SARS CoV-2 S1 Ig G is also positive (1.39).