Age: 32.0
Sex: F
Vaccine: COVID19
Symptoms: Pyrexia, Red blood cell count decreased, Red blood cell sedimentation rate normal, Red cell distribution width increased, SARS-CoV-2 test negative
Clinical narrative: Pt states she had weakness that began about 30 minutes after vaccination.  This included muscle spasms and muscle pain "all over."  She states she had flu-like symptoms for ~1.5 days after vaccination and then felt ok until approximately 3/22/2021, when muscle weakness began and has not stopped. She presented to another hospital on 3/29/2021 to the emergency room and "had a full work-up including EKG, x-rays, and lab work" and was told she had a viral illness.  She was given a prescription for azithromycin and ibuprofen, as she was complaining of sore throat. She presented to the emergency room on 3/30/2021 with c/o generalized weakness, back pain, myalgias and chest pain.  She also c/o fever and chills.  Temp in the ER was 98.5F. Physical exam revealed "diffusely tender abdomen, no rigidity or guarding" and "diffusely tender back all throughout."  3/31/2021-saw family physician w/ c/o cough and myalgias, negative for back pain and chest pain/palpitations. Sore throat and cough were improved.  Was diagnosed with an apparent viral illness and supportive care.  She was advised this could be a viral illness and discharged to home in stable condition. 4/11/2021-Pt reports she went to urgent care b/c felt she had a bad ear infection and eyes were hurting (mostly right); was diagnosed with sinus infection and that ears looked ok. Was told to stop azithromycin and begin amoxicillin and ibuprofen. 4/16/2021-presented to emergency room.  "Patient with 3 weeks of progressive symptoms of headache, blurry vision, nausea, weakness, and poor control of her bowel and bladder. Symptoms are constant with gradual progression with a duration of 3 weeks.  Timing is constant.  Severity is now severe.  Quality is sharp, tight headache."  Vision changes got worse when she was on the flight there. "No exacerbating or alleviating factors.  Not associated with fevers.  Does have some nausea and muscle aches.  Diffuse tremors and difficulty walking without assistance. PE revealed mild psychomotor retardation, tremulous and diffuse weakness, and Romberg present.  Mild right sided papilledema. 4/17/2021- further HPI recorded-The patient is presenting for evaluation of headaches, paresthesias, numbness.  The patient is a fairly good historian and tells me that symptoms began after she received the Johnson & Johnson COVID-19 vaccine.  Patiet began to feel fatigued, malaise, numbness and weakness over the legs.  Patient had some mild blurriness of vision in the right eye.  Symptoms have been persistent and patient began to have some difficulty with walking and feeling off balance.  Patient describes the headaches as primarily right-sided.  According to nursing staff, the patient has also had some incontinence of urine today.  Patient has had some numbness over proximal legs and "private areas". 4/19/2021 ? Assessment as per Infectious Diseases physician; Pt with continued intermittent headaches. Has continued difficulty bearing full weight due to unsteadiness. No loss of sensation at arms/legs. Has action tremor, wide gait, hyperreflexia of arms/legs bilaterally. ADEM Hyperreflexia CSF pleocytosis Fatigue Headache, new onset  Patient has nonspecific findings of CSF pleocytosis as well as clinical findings concerning for ADEM. No infectious cause for this problem; temporally associated with receipt of Janssen COVID vaccine. 4/19 Assessment as per Neurologist; Question of transverse myelitis/ADEM: Perhaps induced by the Covid vaccine On steroids MRI scan of the thoracic spine shows demyelination but no contrast enhancement Continue to work with therapy services No signs of CNS infection and antibiotics discontinued.   The patient continues on methylprednisolone 500 mg iv q 12 hr at this time (4/19/2021).