Age: 59.0
Sex: F
Vaccine: FLU3
Symptoms: Ataxia, Autoimmune disorder, Balance disorder, Blood thyroid stimulating hormone normal, Burning sensation
Clinical narrative: Generalized autoimmune inflammatory response to flu shot - headache, gait ataxia, paresthesia, photosensitivity, arthralgia, myalgia, fatigue. 11/4/12 started prednisone 40 mg PO daily x 5 days - premedication for flu shot - suggested by allergist due to cough, myalgia, tingling in face, photosensitivity following flu shot in 2011. Treated with prednisone following flu shot in 2011. Symptoms resolved within a few weeks. Felt weak, shaky, stomach pains following prednisone started on 11/4. 11/6/12 2pm received flu shot in Dr office - no immediate reaction in the office. 11/6/12 healthy before the flu shot. PM - 11/6 - nasal congestion, tight chest - no cough, no wheeze. 11/7/12 headache, dizzy, muscle aches, joint pains, extreme fatigue. 11/9/12 finished prednisone - severe muscle and joint pains, severe fatigue felt short of breath, very uncomfortable - no fever, no cough, no wheeze. 11/10/12 felt more short of breath, tight, shallow cough, no wheeze - no relief from albuterol. Allergist in Dr office ordered prednisone 30mg daily x 3 days, then tapered to 10 mg/day x 3 days. PM - increased muscle pains across chest below collar bones, across back, hips, legs felt very tired, weak, rubbery. Tingling in feet, hands, face, severe headache, numb feeling in face. 11/11/12 - still felt short of breath, increased tingling, burning in soles of feet, tingling of hands, headache, decreased muscle aches and joint pain. 11/12/12 - allergist suggested neuro exam needed. Continued tingling of hands, feet, face, lower legs felt rubbery - fatigue, still feel short of breath. 11/13/12 hospital ER visit - evaluated by neurologist same symptoms as 11/10-12 also feel like there is a tight band below Rt. knee around leg. Reflexes (+), normal muscle strength. Eyes now increased sensitive to bright light. 11/16/12 - follow up visit Dr - dizzy, headache, tingling hands and feet, cold and hot intermittent sensations - hands and feet, fatigue, feel weak knees down and weak feeling lower back, face numb - intermittent. 11/20/12 TSH result 5.5 from ED visit 11/13 = "normal elevation following prednisone". ANA (-). 11/21/12 MRI of Brain = normal. 11/23, 24 fatigue, increased dizzy with loss of balance, feet tingling, intermittent hot and cold, numb, hot, burning, shooting pains in fingers, toes, knees, about rib cage. 11/25 - increased sensitivity to bright light, fluorescent lights - can't stay in bright lights need sunglasses even in the house. 12/12 labs done ANA borderline (+), Vit D = 23, TSH = normal, ANA Screen IFA = positive, ANA titer 1:40. 12/25/12 increased shooting burning pains (L) arm and (L) leg, still tingling numbness of hands and feet -> cold, numb, burning, fatigue. Increased eye pain with bright lights - need sunglasses with bright lights, bright sunlight, car headlights at night - still unable to drive, increased headache with bright or fluorescent lights. 1/7/13 Nerve Conduction Studies, EMG = normal. 1/15/13 Eye exam - no nerve damage seen. 2/18/13 still increased sensitive to bright lights, (+) shooting intermittent pains in extremities, tingling of hands and feet, burning of feet, numbness (L) hand and (L) foot. Sharp pain (R) temple, (R) ear, (R) jaw. 2/28/13 MRI of Neck = normal. 3/7/13 skin biopsy - negative for small fiber neuropathy. 3/24/13 still tingling lips, face, hands and feet, feet burning at night, intermittent cold and numb hands and feet - (L) side worse than (R) side. Still shooting pains through hands and feet, still intermittent pain (R) side of face and jaw, occasional blurred vision - intermittent with fluorescent light. Unable to tolerate bright sunlight, fluorescent lights. 4/3/13 eye exam - no optic nerve damage - eyeglass prescription change - tinted lenses, dark sunglasses. Increased difficulty focusing eyes with fluorescent lights, increased eye fatigue and pain. 4/16/13 Dr - still loss of balances, photosensitivity, tingling - numbness hands and feet, to wrist and ankles. 5/8/13 return to work 4 hours/day desk job - unable to do patient care as an RN. Wear sunglasses in needed with fluorescent lights - increased eye pain and fatigue after 4 hours of fluorescent lights, unable to drive at night - headlights too bright. 5/3/13 -7/1 rheumatology work up - R/o autoimmune diseases - no MS, no lupus. Labs - negative. ANA - normal. Probable Autoimmune Reaction. Stopped CRESTOR. 8/1/13 Prednisone 7.5 mg daily x 1 month ordered by rheumatologist. 9/13 worsened symptoms increased tingling and burning of hands and feet, increased numbness (L) hand and (L) foot tingling and numbness - elbows and knees. Increased sensitivity to lights, increased ataxia, increased pain (R) temple, (R) ear, (R) jaw. Increased shooting pains in arms, legs, hands and feet. Unable to tolerate trials of NEURONTIN, LEXAPRO, CYMBALTA, LYRICA due to increased fatigue, unable to function. Ongoing medical care by neurologist.