Age: 62.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Headache, Hypoaesthesia, Immunoglobulin therapy, Injection site pruritus, Intensive care
Clinical narrative: 1/22/21 0841 ED MD DOCUMENTATION: Patient is a 62 year old female, with a past medical history of hypertension, hyperlipidemia, hypothyroidism, and hysterectomy who presents to the ED for evaluation of gradually worsening symptoms of sensation changes described as tingling and pins and needles in her hands that began following her COVID vaccine 1/5. Patient has a written timeline of her symptoms she has brought with her that detail the course of her symptoms and onset. On 1/11, she began having generalized itching, on 1/13 her itching was worse in her palms and soles of her feet which she took Benadryl for. She was seen at urgent care 1/16 and was started on hydroxyzine and a Medrol dose pack. 1/17 she began to have a "weird palm sensation" and 1/18 she began to have arm and back pain. Since 1/19 she began to have ataxia, vertigo, and worsening paresthesias in her hands and feet. 1/20 she began taking the steroid with worsening symptoms. Last night she was unable to sleep due to diffuse itching. Patient has associated symptoms of vertigo, ataxia. Denies headache, chest pain, shortness of breath. Patient denies smoking, alcohol consumption and drug use. Patient is allergic to minocycline. Patient denies any other symptoms at this time  1/22/21 1029 H&P: 62-year-old female with history of essential hypertension on medical regimen, hypothyroidism on replacement therapy, and dyslipidemia on statin therapy, was in her usual state of health until 5 January.  She at that time had them O'Beirne coronavirus vaccination first dose.  After several days she continued to have injection site itching, which progressed to full body itching and tingling especially involving the palms and the soles, for which she was treated with Benadryl and Zyrtec without effect.  Ultimately, she was placed on hydroxyzine and a Medrol Dosepak, which did not improve her symptoms appreciably.  She continued to have altered sensation, along with bilateral arm and back pain for the next several days, and approximately 2 days prior to admission she developed ataxia, and vertigo. 1/22/21 1938 NEURO CONSULT: 62 yr old R-handed woman with no prior neurological symptoms who acutely developed rapidly progressive paresthesia first and then ascending paresis from the bilateral LEs and then to the UEs preceded by spreading itchiness 6 days after the Moderna's COVID19 vaccine taken on 1/5/20. Today she has diffuse paresthesia worse in the distal limbs and paresis in the LEs w/ mild ataxia and the distal UEs. No sign of bulbar involvement or respiratory distress. Clinical story and examination are most consistent w/ post-vaccine AMSAN (Acute Motor and Sensory neuropathy), a variant of Guillain Barre syndrome (GBS). CBC and CMP, UA unremarkable. CT head and MRI brain on my review only showed a chronic one small oval white matter change. EKG on my review showed normal sinus rhythm.    Good recovery can be expected with early treatment. If the neuropathy spread to the respiratory and bulbar muscles, she will rapidly decline to acute respiratory failure.    RECOMMENDATIONS: - Ordered IgA level and IVIG 400 mg/kg daily for 5 days.  - Check vital capacity and NiF q4hrs (ordered). If vital capacity falls below 15-20 mL/kg or NIF below -20 mmH2O, must intubate STAT given the impending respiratory failure. Instructed the ICU RN.  - BiPAP may delay and avoid intubation.   - watch out for cardiac arrhythmia and SIADH.  - steroid has no role here.  - ordered serum anti-GM1, anti-GD1b (ganglioside panel).  - Hold off on all blood thinners after midnight tonight for possible LP (ordered) tomorrow.   - Ordered CSF cell counts x2, protein, glucose.  - Bed rest. 1/23/21 0953 NEURO PROGRESS NOTE: Strengths are mostly normal and improved except for the hand grips, elbow extension as well as mild to moderate ataxia of the LEs. The face and respiratory muscles are spared so far w/ good vital capacity and NIF. CBC and CMP, UA unremarkable. CT head and MRI brain on my review only showed a chronic one small oval white matter change. MRI cervical and thoracic spine unremarkable and no evidence of Transverse myelitis or Multiple sclerosis. She is already improving after the first dose of IVIG last night which she tolerated well. CSF collected today showed the expected albumin cytologic dissociation consistent w/ AMSAN/GBS (normal WBC but elevated protein to 66.