Age: 40.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Hypotonia, Immunoglobulins normal, Immunology test, Impaired work ability, Legionella test
Clinical narrative: Following my second Pfizer dose on on 4/2/21 I began having a strong burning pain in my right forearm and wrist area. I perceived this initially to be carpal tunnel and it started on 4/5/21. I self treated with ibuprofen for a few days with no improvement, then saw my PCP on 4/9.  My PCP thought this to be tenosynivitis, and prescribed Methylprednislone. The steroid treatment helped for the first few days but then the pain quickly spread to my right leg in the thigh area. Same type of pain, burning and intense. I was able to walk, but with a slight limp.  I saw my PCP again on 4/15 to discuss the new symptoms. He began researching possible conditions and also ordered some blood tests for common auto-immune diseases (Uric Acid, C-Reactive Protein, CMP, ANA). Everything returned normal except for C-Reactive (value- 50+). To be sure it wasn?t a case of septic arthritis, I was placed on an antibiotic on 4/17 (Keflex) for 7 days.  The Keflex did not help and actually gave me a slight fever (100.1) and I missed work on 4/19,20,21. I started to improve on 4/16 but the symptoms were still present.  As a followup, my PCP ordered a more comprehensive blood panel to be reviewed at my next appointment on 4/30. The following blood tests were ordered: TSH 3rd Gen Blood, CBC, CMP (BAMP, TP ALB TBIL,ALK, AST, ALT), and LIPID Panel.   On PCP appointment on 4/30, my symptoms continued to present in legs and right arm. All values from blood tests were normal. He ordered a lower back xray, which was scheduled for 5/11. At this point, my PCP referred me to a rheumetologist as he had exhausted his options.  Unfortunately, the earliest rheumatology available was 5/18.  On 5/18 appointment with rheumatology resulted in more tests: Parvovirus B19, Rheumatoid Factor, Serum Protein Electrophoresis, Urine PRotein/Creatinine Ratio, Immunoglobulin Assay-Blood, Immunofixation Procedure Blood, ASO- Blood, CPK Blood, Cyclic Citrullinated Peptide Antb, Hep B Surface AG, Hep C AB- Blood, Microalbumin urine random. All tests read as negative or normal except ASO.  Rheumetologist referred me to Infectious Disease for further testing on 5/26, which resulted in the following blood tests: Ehrlichia Chaffeensis AB IGG, DNASE B Antibody, HLA Typing A B C Single - Blood, Legionnella -Blood, Prostate Specific Antigen, Unrinanalysis with Microscopic, Chlamydia and GC RNA AMP, Upper respiratory throat culture. He also ordered an ECG, a chest XRAY (PA and Lateral), CT scan of the pelvis. On 6/4 at a followup appointment, he ordered Crypto AG and C-Reactive Protein. At this point, CRP value was 180.74.  I worked my last day of work on 5/14 as the pain became too intense to manage. As the week progressed, I slowly lost my ability to walk and care for myself. I could walk only 10-15 feet at a time, and doing so would cause a severe flare-up of pain in my legs. I was mostly bedridden for 2 weeks starting on 5/20 and was only getting up very minimally. I needed a wheelchair for transport to my appointments on 5/25, 5/26, 6/2, 6/3. By 6/4, I was barely able to walk to that appointment, but the office is very small so I was able to make a short distance.  My rheumetologist, having reviewed all my normal test results ordered an EMG on my legs and right arm and also an MRI on my lumbar and cervical.  EMG conducted on 6/24 and revealed some nerve damage and signs of neuropathy in my legs; and also carpal tunnel in the right wrist.  MRI Lumbar (6/25) revealed some common lower back issues, but nothing affecting the nerves that may be the cause of my symptoms. MRI Cervical (7/12) completed but yet to be analyzed.   As of today, July 12, I?m feeling much improved over how I felt in early June. I can walk a short distance of ? mile without needing a break. I have lost muscle tone and need to work on getting my strength back. My right arm has minimal pain but will flareup with heavy computer usage.  However, for the past 2 weeks, my left arm (which has been symptom free since April) now has a similar burning pain that starts at the funnybone of the elbow and runs up to my wrist. The pain comes and goes but is sometimes very intense and can be debilitating. It is hard for me to open some doors with this hand or even hold a heavy cup of water.  As a previously healthy person, and having done exhaustive testing, myself and my PCP believe I had a rare and negative reaction to the vaccine.