Age: 38.0
Sex: M
Vaccine: COVID19
Symptoms: Injection site hypoaesthesia, Injection site pain, Injection site paraesthesia, Lipids normal, Lumbar puncture
Clinical narrative: 5/12/21 approx 4:30pm first shot moderna left shoulder 5/13/21 typical soreness left shoulder  5/14/21 typical soreness left shoulder  5/15/21 light numbness and tingling in left arm and hands and left leg and foot 5/15/21-5/19/21 numbness and tingling got progressively worse and moved to both sides 5/19/21 spoke to doctor via virtual visit he said I needed to talk to my PCP. 5/19/21 talked to my PCP he recommended I go to the ER to he checked for stroke 5/19/21 I went to ER, they did CT scan and ultrasound on my legs from groin to upper calve. Tests were negative. They gave me one Ibuprofen and referred me back to my PCP.  5/20/21 spoke with PCP he gave me a prescription for Gabapentin to try 1 at lunch and 1 at bedtime - zero noticeable effect, no sleepiness, drowsiness, tired feelings 5/21/21 informed PCP of zero results so changed to 1 at lunch 2 at bedtime - zero effect no sleepiness, drowsiness, tired feelings 5/22/21 informed PCP of zero results so changed to 2 at lunch 3 at bedtime - zero effect no sleepiness, drowsiness, tired feelings 5/23/21 informed PCP of zero results so changed to 2 at lunch 4 at bedtime - zero effect no sleepiness, drowsiness, tired feelings 5/24/21 informed PCP of zero results so changed to Lyrica 1 each 50mg in morning 1 each 75mg - zero effect no sleepiness, drowsiness, tired feelings 5/25/21 informed PCP of zero results so changed to 1 each 50mg in morning 2 each 75mg - zero effect no sleepiness, drowsiness, tired feelings 5/25/21-5/27/21 continued 1 each 50mg in morning 1 each 75mg - zero effect no sleepiness, drowsiness, tired feelings 5/27/21 informed PCP of zero results so referred me to Dr. Neurologist.  5/28/21 at 0945 spoke with neurologist she recommended I come back at 12 for testing 5/28/21 at 12 come back to neurologist for EMG tests. Results: muscles and large nerves are good. She referred me to get a MRI and spinal tap. 5/29/21 about 12:15pm I go ER. Have spinal Tap and MRI of head and spinal chord. Did spinal tap before mri. First attempt at spinal tap 15-20+ pokes unable to get spinal fluid. Pause for mri 2+ hours consisting of 1-1/2 hour-ish session and 30 minute-ish session. Ended at 6:15. Back to room waiting for mri results and a different doctor to try spinal tap again. Dr. was successful going higher up and was able to extract the spinal fluid as required. Released from ER and went home. 5/30/21 stayed in bed took some Advil. Received call from Dr. that she wants to do IVIG treatment starting Tuesday 6/1. 5/31/21 stayed in bed mostly. Start feeling sight sinus pressure so take some Sudafed.  6/1/21 8am-10:30am (got through at 10:30) called Dr office to set up appointment for IVIG treatment. Receptionist had to talk to Doctor and call me back. Symptoms are same as neuropathy tingling and numbness in hands and feet and moving up to arms and legs. 6/1/21 Dr. prescribes Cymbalta (generic) 30mg once daily until IVIG procedure can be scheduled.  6/2/21 taking cymbalta 1 per day 30mg. No noticeable effect 6/3/21 taking cymbalta 1 per day 30mg. No noticeable effect. 6/4/21 taking cymbalta 1 per day 30mg. No noticeable effect.  6/4/21 went to lab for glucola 2 hour and other blood tests lipid panel/etc by direction of Dr.  6/5/21-6/6/21 taking cymbalta 1 per day 30mg. No noticeable effect. 6/7/21 spoke to Dr.  she said All blood results were negative and normal but if levels were too low to recommmend IVIG treatment. Also recommended I take gabapentin 3 times daily along with cymbalta. (Not wanting to do that at this time). 6/7/21 I sent Dr. and email asking if she had tested me for B1/B12 deficiency and of a SFN autoimmune panel can be done. 6/7/21 I contacted pain center on about Sanexas treatment. Got appt for screening for 6/8/21@10:00am. 6/8/21 went to sanexas screening. Going forward with treatment scheduled exam/biopsy  for 6/9/21@11:15am. 6/8/21 Dr.  returned my query about B12/panel etc and I am picking up an order today to get those tests done. More blood draw. 6/8/21 went to lab and had blood drawn for vitamin B tests etc. 6/9/21 sanexas exam and nerve biopsy complete. Scheduled first treatment for 6/10/21 6/10/21 sanexas treatment #1 6/11/21 sanexas treatment #2 6/14/21 sanexas treatment #3 6/16/21 sanexas treatment #4 6/17/21 Dr. called to let me know the B1-6-12,etc bloodwork came back all good. No deficiencies and all normal. She requested I get a referral to another neurologist to discuss other optional potential treatment. Called my pcp and they gave me a referral. Have to call tomorrow 6/18 to request an appt with new neurologist. 6/18/21 sanexas treatment #5 6/18/21 called new neurologist Dr. to set up appt.  6/21/21 sanexas treatment #6 6/21/21 results of nerve biopsy show small fiber nerve degeneration. 6/21/21 TM Flow test at Pain Center. Test shows degeneration of small fiber nerves.  6/23/21 sanexas treatment #7 6/25/21 sanexas treatment #8 6/28/21 sanexas treatment #9 6/29/21 spoke with Dr. she said in an attempt to see another neurologist sooner I should go to the ER and ask for a neurologist.  6/30/21 sanexas treatment #10 7/2/21 sanexas treatment #11 7/4/21-7/27/21 I had to fly myself and my 11 year old son to another State to be with my mom who was rushed to the ICU due to her several conditions thinking she may not make it through this time. While up there I had to address all the the final issues in the worst but inevitable event that she may pass. She eventually stabilized enough for me to return while knowing that she is due to have heart failure at any moment.  7/21/21 initial video consult with Dr.  7/27/21 return to other State 7/29/21 sanexas treatment #12 7/30/21 @7:45am seeing 2nd Neurologist Dr. for initial in person consult 7/30/21 Dr performed another EMG test. Is going to consult with Dr.  to discuss next treatment. Potentially steroid treatment. 8/2/21 sanexas treatment #13 8/4/21 sanexas treatment #14 8/6/21 sanexas treatment #15 8/9/21 sanexas treatment #16 8/11/21 sanexas treatment #17 8/13/21 sanexas treatment #18 8/16/21 sanexas treatment #19 8/18/21 sanexas treatment #20 8/23/21 sanexas treatment #21 8/25/21 sanexas treatment #22 8/30/21 sanexas treatment #23 9/1/21 sanexas treatment #24 - FINAL One Complete 9/13/21 No Noticeable difference. Same Tingling Numbness Neropathy symptoms in Hands/Feet/Arms/Legs. Can't get IVIG Treatment due to potential Anaphalexis. Nerologists are discussing a potential Steroid Treatment.