Age: 62.0
Sex: F
Vaccine: COVID19
Symptoms: Anti-cyclic citrullinated peptide antibody negative, Antiacetylcholine receptor antibody, Antinuclear antibody, Antinuclear antibody increased, Antinuclear antibody negative
Clinical narrative: A 63-year-old female with a medical history of Hashimoto?s Disease, on Levothyroxine 88 micrograms (4 days per week) and 100 micrograms (3 days per week), presented to the emergency department with a 7-day history of acute onset of severe, debilitating, fatigue, weakness, anorexia and malaise. She had no clear precipitating events, stated that she was in her usual states of health, active, working as an optometrist at a University hospital. Stated that 1 week before symptom oncer she had her first dose of Moderna COVID-19 Vaccine EUA. Stated that 24hrs later her symptoms started associated with low grade subjective fever, however her fever disappeared, and she persisted with severe fatigue. She was unable to do her regular activities of daily living and was hoping her symptoms would resolve but upon persistence and given the severity of her complains she presented to evaluation. She denied recently starting any new medications/supplements, or recent change in her levothyroxine dose. There were no headaches, cough, diarrhea, sore throat, rhinorrhea, myalgia, arthralgia, weakness, recent infectious illness or sick contacts. She was diagnosed with Hashimoto?s Disease over 10 years prior and had been on the same dose for more than 2 years.   VS were stable and within normal limits, physical exam was only remarkable for weakness on 4 extremities 4/5, lethargy, bradylalia, bilateral ptosis, no focal neurologic deficits, sensation intact. Laboratory workup revealed normal Hb 14.8, normal renal and kidney function, normal cortisol level, TSH normal 3.7, normal FT4: 1.2, normal CPK, negative tox screen. ESR and CRP were performed, and both were found to be elevated ESR 74, CRP 28, at that moment we decided to do immunologic workup showing high titers of ANA >1:320 with a nuclear speckled pattern, and a positive rheumatoid factor 60. At this point a full rheumatologic panel was performed which was negative for anti-Ach receptor Abs, negative anti-CCP, anti- dsDNA, anti-smith, negative anti-Jo1, anti-RNP, negative anti-TPO, negative anti-SCL70, normal C4 and C3 however elevated total CH50 > 60, positive anti-SSA and anti-SSB. Her symptoms of severe fatigue persisted throughout her admission and it was decided to give her a course of prednisone 40mg for 5 days and follow up as outpatient with a Rheumatologist. Repeat workup 2 weeks after discharge showed still elevated ESR at 72, high CRP 17, rheum factor elevated again at 67.  At this point no clear cause was identified as she did not have any symptoms of Sjogren or anything else other than severe persisting fatigue.  Another course of steroids was given and 1 month later she stated that she was much improved and was able to go back to work. Stated that she would not take her second covid MODERNA vaccine dose due to fear of recurrence of symptoms. It appeared that this vaccine triggered a severe inflammatory and autoimmune reaction in this patient with history of Hashimoto?s disease. The association between MODERNA vaccine and development of autoimmunity and inflammatory reaction needs to be assessed.