Age: 35.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Platelet count normal, Pneumonia, Rheumatoid factor negative, Scan with contrast, Sensory disturbance
Clinical narrative: On April 6th she received the Johnson and Johnson Covid vaccination. She was asked to wait 30 minutes longer when she mentioned a past allergic reaction to Levaquin which caused visual disturbances. 2 minutes after she sat down to wait the 30 minutes she began to have what felt like an adverse reaction.   The floor tiles were morphing/melting together, her heart began to race, it felt like she had a very strong palpitation that took her breath away,  she felt short of breath, and she felt heat radiate from her neck to her ears. It felt as if she  was going to pass out in her chair.   She alerted the medic and was made to wait an additional 40 minutes in that area. A nurse monitored her and explained it was syncope and suggested she had needle phobia(she has never had a problem with needles before.)    After this occurred she drove back to home very confused as to what had happened.  That evening after the vaccine she had horrible leg pains and was incredibly exhausted. She went to bed early feeling achy in her joints like she had the flu setting in with some nausea.   The next couple of days were very confusing and she had what felt like intense mania. Her heart rate had not returned to normal and she was beginning to take notice. Her heart just felt like it is beating "hard" like the bounding heart feeling she remembers from when she had mononucleosis. When she stood up for long periods of time she felt faint, almost immediately.   On April 15th, she ended up calling 911. She thought she was having a heart attack. Her heart began to race very fast suddenly while she was rolling balls of playdough with her 3 year old son and she started noticing weakness in her arms, brain fog, heavy chest, and what felt like tightening of her heart muscles. She was having trouble catching her breath as well.   When the ambulance got there they clocked her temp as 102 F. . When she arrived at  Hospital  they assessed her and ran an EKG which revealed at the time the heart was fine, even though it was racing very fast and feeling as though it was being over worked.   They ran a chest X-ray as well, and blood work. Before any results came back they offered her an Ativan for ?panic attack?, she was at that point ready to check herself out. When she mentioned this began 2 minutes after the vaccine they pretty much looked at her as if she was being paranoid due to the fact it was the J&J vaccine. When the results came back they told her she had pneumonia and sent her on her way with a Z-Pack. She left that afternoon still feeling very sick and confused, but she assumed it was all related to her ?pneumonia? diagnosis. Sometime after that ER visit she began developing ear pressure behind her right ear (which later spread  to both ears) that was intense.   It would heighten if she was standing or talking for too long and it would build the pressure throughout her head causing severe pain. It radiated from her head to the back of her neck and into the jawline even. Noise seemed to also be a trigger/ make it worse. The only relief she got was laying down.  She began having unusual ?spells? daily some time after that and it became debilitating. She is a stay at home Mom of a 3 yr old boy, and 2 yr old girl and it has not been easy making certain she is all the Mom she can be for them lately.  When these spells occur, it almost feels as if she is having either a stroke or a heart attack and she is left feeling very confused and utterly exhausted afterwards. She would have shaking all over like her legs were shaking also her hands shook and she got confused. The shaking lasted about 3-4 minutes then she feels exhausted afterward. Her heart rate would also go up before the shaking. She did not go completely unconscious with the spells. Her husband describes the spells also as shaking of the limbs lasting no more than 3-4 minutes.  On April 22nd she ended up seeing her PCP, . He sat down and listened to everything she had to say and was very thorough with testing.  He also noticed abnormal amounts of fluid on her right ear and prescribed her Claritin, also for precautionary measure he put her on  Aspirin as well. He diagnosed her with probable Lyme disease and started her on Doxycycline 100mg twice daily, for 3 months.   Since seeing the Doctor she has noticed daily symptoms but with some improvement, she thinks thanks to the Doxycycline, though some symptoms are new. They seem neurological to her and that is concerning. Her left eye sometimes involuntarily moves on its own- it looks/deviates upward and to the left  2-3 times  a week for a few seconds.  Her arms tend to tingle and feel weightless at times for a few seconds 2-3 times a week.   Her legs tend to buckle under sometimes at the knee or ankles like her knees are forgetting how to carry her weight or like she is drunk, also only lasts a few seconds but 5-6 times a day. She has blurred vision that seems to come and go, worse in mornings and evenings that started in April. Mainly in the am when trying to read small print. But other times eyes are fine. She also has pulsations of her irises going larger and smaller like they are pulsating- that comes with the bounding heart. That can last several minutes to several hours. It comes and goes now, but was all day back in May and June. She also had a weird buzzing or vibrating sensation within her body, almost feels like it stems from her spine in the center.  It was in her back/spine at first.  Now it is in her legs and left ankle like electricity inside of her body. Can last 20-30 minutes 4-5 times a day.  It was a very sharp pain when it happened in the back, but now it is not really even a pain, it is much milder.   . The veins in her head throb, and pulsate irregularly. That was in the left parietal region and she could see it move there.   Now she also has random muscle twitching in her left thigh, both sides/lateral ribs, Upper chest under the rib cage, the upper arms, now  most recently the fingers are twitching randomly middle finger of L hand, and 4th and 5th finger  of her R hand, and L foot. This has been more in June and July. She also has twitching at night when she falls asleep.   When lying on her r side her face twitches and pulls forward   These symptoms were ongoing at the time of her first visit with me 7/15/21