Age: 30.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Electrophoresis protein, Exercise tolerance decreased, Fatigue, Fibrin D dimer normal, Full blood count normal
Clinical narrative: FOLLOW-UP TO A PREVIOUSLY SUBMITTED VAERS REPORT 0949661-1 Notes per Medical Records and patient history: On 15 Jan 2021, went to ER - Chest pain, tingling of right arm, nausea, elevated BP and heart rate. One hour after vaccine receipt on 14 Jan, experienced 30-45 min episode of right-sided chest pain with radiation to right arm. Later that afternoon, similar episode of chest pain. Awoke in middle of night with similar episode. Episode today more severe and associated with lightheadedness and near syncope. No leg swelling or rashes. PHYSICAL EXAM: WNL. Released in stable condition with instructions to follow-up with PCM. Per patient - EKG was reported as normal. Vital signs were normal except BP 140/84 (higher than usual for patient). No labs done. Anxiety considered a factor. 18 Jan 2021, ER visit - Several intermittent episodes of chest pain since 14 Jan. Now, more midsternal and lasting longer; non-exertional and non-positional. No SOB; no diaphoresis. No fever/chills, myalgias, cough, sore throat, nausea/vomiting/diarrhea. Initial BP 157/90. PHYSICAL EXAM: WNL. CXR and ECG normal. Treated with Toradol. Cardiology consulted and recommended obtaining a Troponin, D-dimer, and CRP, and trial of Colchicine and Naprosyn, and to schedule a stress echo. DX: Chest pain, unspecified 26 Feb 2021, ER visit - Chest pain intermittently x 7 weeks, with increase in pain for past several hours. Pain described as tightness across bottom of lungs and upper abdomen. Seen by Cardiology with no evidence of ischemia or pericarditis. Took colchicine x 3 days with no relief. Since Cardiology work-up, pain decreased to 1/10 intensity. While having dinner tonight, felt sudden onset of stabbing pain in mid-sternal region. Also noted onset of associated shortness of breath. Current chest pain is localized to mid-sternal region; exacerbated with deep breaths and somewhat alleviated with lying down. Pain now is 6/10 after taking naproxen prior to ER arrival. Also reports new onset frequent headaches and nausea. Had brain MRI yesterday and is awaiting Rheumatology evaluation for possible autoimmune disease. BP 143/81. PHYSICAL EXAM: WNL. Treated with GI cocktail (felt worse after).  Had bedside ultrasound (normal gall bladder; no gall stones). ECG normal/no changes. Troponin - negative. CBC, CMP, Lipase unremarkable.  Possibly inflammatory/chest wall pain. Continued Naproxen recommended.  3 Mar 2021, Rheumatology consult - Acute onset of syndrome characterized by chest pain with some radiation to the right side and intermittently to the right shoulder, episodic, moderate to intense, partially responsive to naproxen. Malaise, fatigue, especially in the morning; decreased exercise tolerance due to lower energy. Also reports recent frequent, intermittent headaches - bilateral temporal. No history of chronic headaches.  Episodes interspersed "good days" without chest pain but with persistent malaise, fatigue, decreased tolerance to exercise. Decreased tolerance to exercise is not so much dyspnea on exertion but fatigue and feeling spent after half a workout of what she was able to do before. No hair loss, rashes, sicca syndrome, oral ulcers, pleuritic chest pain, GI changes, inflammatory arthritis, muscle weakness or neurological complaints.  PHYSICAL EXAM: WNL 17 Feb 2021- ANA 1:40 speckled. Negative ANCA, complement components C3, C4, urinalysis, SPEP ASSESSMENT/PLAN: Onset about 2 hours after the 1st dose of Pfizer Covid 19 vaccine in very healthy individual, physically fit, helicopter pilot. Unremarkable physical exam, laboratory tests and recent stress echo. Negative MRI of brain.  Doubt a systemic autoimmune disorder. Discussed prevalence of low titer ANA in general population and relatively low predictive power of test. Recent studies of the vaccine have reported some patients with complaints of pain and findings of enlarged lymph nodes,; she has no findings to suspect myocarditis. Aortitis cannot be ruled out. The onset 2 hours after the 1st dose of the vaccine in a previously very healthy individual suggests some form of reaction.  Pericarditis has not been found on echocardiogram. I wonder if a cardiac MRI with and without gadolinium may be useful. Alternatively, a CT scan of the chest with contrast may be useful. Specific autoantibodies were ordered.  Recommended another trial of colchicine 0.6 mg daily x 2 or 3 weeks along with Naprosyn 500 mg 1 to 2 times daily.  23 Mar 2021, Rheum follow-up - ASSESSMENT/PLAN: Unusual, new onset, episodic chest pain, short lived, associated with malaise and decreased tolerance to exercise. Naprosyn, when used, helps for the day...Discussed the option of observing and treat symptomatically and continue to do studies or consultations as needed or to intervene, on an empirical basis with short course of prednisone assuming some unresolved inflammatory process. ( 20 mg in the morning x 4 days, 15 mg x 4 days, 10 mg x 4 days, and 5 mg x 4days). Ordered CRP, CBC, SPEP, ESR. 26 Apr 2021, Pulmonary (video) - referred for evaluation of atypical chest pain and exertional dyspnea. 30-year-old CG helicopter pilot who describes being in very good general health until clinical episode began in Jan. She is a runner and was training for marathon at baseline...2 hours after her 1st dose of COVID vaccination, she felt rapid onset chest tightness, more on right side. Right arm felt numb; seen in emergent care...Symptoms include right sided chest heaviness and pain, now migrating to left side. Can be stabbing pain in nature. No prior similar symptoms. Denies asthma as kid. One pneumonia in second grade. Never smoker; no second hand smoke. Helicopter pilot, some jet fuel exposure, flies for Coast Guard. Has not had second dose of COVID vaccine. From onset to now, initial improvement, some fatigue early on, 2-3 weeks later fatigue on plateau, then headaches, pain on both sides of chest, prednisone given and fatigue improved, headaches went away but then came back, milder, short term in nature. Chest pain has increased to constant as weight in bottom of chest.  Was big runner before, training for marathon, now down to running a mile, exertional chest pain and heaviness, stabbing pain usually low down sometimes right of sternum. Takes few hours to subside.  Treatment included a prednisone taper, made chest symptoms worse but made fatigue and headaches better. Colchicine led to no improvement. Currently on Naprosyn and Tylenol for pain.  CLINICAL IMPRESSION: Never smoker, good baseline health, runner.  4 months ongoing R>L chest pain, onset within 2 hours of 1st COVID vaccine.  Fatigue, improved on steroids.  Headaches, improved on steroids.  Exertional dyspnea, persistent. Normal tests include chest radiograph, ESR, CRP, ECG, Stress test and reportedly CT, but not see by this provider; ANA 1:80 likely not clinically consequential.  PLAN:  Obtain outside CT scan; D-dimer and BMP; if positive, consider CT angiogram to r/o PE. PFT and exercise oximetry, COVID screen before test. Continue Tylenol/Naprosyn as need. Follow-up after testing complete.  DISCUSSION: Explained story and normalcy of tests not suggestive of pneumonia, coronary syndrome, asthma, and apparently without underlying collagen vascular disease. Sterile pleurisy seems to fit her scenario better if there is a lung pathology present, but if severe enough to cause symptoms this profound for this long, surprising no lab markers for inflammation are positive. PE can cause dyspnea and chest pain and not show up on x-ray or on noncontrast CT, which was what she reports having had. Would be extremely unusual to cause pain this far out from onset, and hard to explain increase in symptoms with prednisone use. For dyspnea, recommend PFTs first, and for possible clot, review outside CT initially, but in absence of clear answer, move forward with d-dimer check and if positive, then anticipate CT-angiogram to at least exclude dangerous processes. COVID-induced inflammation does not currently have a confirmatory test, although the timing of symptoms onset just after vaccine is noted. Follow-up after above testing.  21 Apr 2021, T-CON: Review of initial symptom onset - Experienced chest tightness within 2 hours of vaccine receipt. The next day, she did not wake up with chest tightness, but later that day while at work, she experienced chest tightness and right arm numbness. She went to the local clinic, who had her go to the ER; at the ER, they thought she was most likely having a panic attack. She reports having brief episodes of chest tightness on 15 - 17 Jan. On Monday, 18 Jan, the chest tightness lasted about 5 hours. She went to the ER and at that time, was told her ECG was abnormal. She was then referred to Cardiology; reports having normal stress test and imaging.  Then toward the end of the month, she experienced increased fatigue (sleeping x 12-15 hours/day). She also started having severe headaches. During her evaluation, it was noted that she had a positive ANA, so she was referred to Rheumatology; told she did not have evidence of an autoimmune disease, but her symptoms were c/w post-COVID "long haulers".  UPDATE AS OF 15 JUL 2021:    Symptoms are about the same. Experiencing constant chest pain that occasionally gets worse. Severe headaches 2-3X/week.; no pattern in symptoms; they seem to come on spontaneously without a trigger. Initial Neurologist evaluation last week. No specific diagnosis, but assessed as borderline chronic migraines; will follow up later in the summer if the migraines continue. Between the Neurologist and PCM, initiated prescriptions - Riboflavin 400 mg/day, Magnesium oxide 250 mg 2x/day and Petadolex 75 mg 2x/day.  Had first virtual appointment with Internal Medicine on 15 Jun; scheduled for a physical on 19Aug.  Applied for the  Clinic but appointment pending (told it would be in about 8 weeks.)