Age: 82.0
Sex: M
Vaccine: FLUA3, VARZOS
Symptoms: Fatigue, Gait disturbance, Immunology test normal, Magnetic resonance imaging brain abnormal, Memory impairment
Clinical narrative: The patient received both the flu vaccine and the first shingles vaccine on 9/23/19. He started feeling tired with body aches the next day. Both the tiredness and body aches increased daily. Then he started to have severe pain in his toes, fingertips and his nose. Thinking he might have a sinus infection he went to urgent care on 10/1/19. He had no fever and they told him he most likely had a virus and that is what was causing the pain. They gave him an injection of Toradol and sent him home. That evening he started to show signs of confusion and forgetfulness but the pain was much better. By 10/4/19 the confusion and memory loss became more severe and he had trouble walking straight. He was also feeling weak. He was taken to the ER and was evaluated. They did a CT scan which was clear. Chest x-ray was inconclusive. They did blood work which showed elevated heart enzymes. Possible stroke. During the night he called his wife once at midnight and the other at 8am he did not know why he was there and demanded to be taken home. The doctors release him on 10/5/19, stating that he most likely had a reaction the vaccines. They also noted that he has the beginning stages of kidney disease. They said that even the elevated heart enzymes could have been a reaction to the vaccines. He has no memory of being in the ER, in the hospital or the calls he made. For the next few days he seemed very tired and continued to have severe pain in his fingertips. His fingertips even developed a red line under the nail beds. His short-term memory still was not improving. On 10/7/19 he saw his primary care physician (PCP). The PCP ordered more blood work and did a chest x-ray. He also ordered and MRI and a consult with a Neurologist. The blood work came back slightly improved. On 10/9/19 he started with a cough, then extreme back pain in the middle of the night paramedics were called. However, by the time they arrived the pain subsided and he declined going to the hospital. The pain was better all of the next day. That night (10/11/19) the pain suddenly started again. The paramedics were called again and this time he was taken to the ER and admitted. More blood work was done. The MRI was done at the hospital and more x-rays. The doctors stated the he has swelling throughout his body. This is likely due to the reaction and what is causing him all of the symptoms. It could have also caused the lining of his lung to have swelling and possible a blood clot. The MRI showed some area's in the back left of the brain that look like bruising, which could have been caused by the swelling. An x-ray was inconclusive to rule out a blood clot due to the beginning stages of kidney disease. (They could not do the tests with contract as this would be harmful to his kidneys.) They cannot rule out that he could have had a stroke and a reaction to the vaccines at the same time. They are going to run more tests. He was given prednisone for the swelling and Eliquis to thin the blood in case of a blood clot. 10/18/19 a vascular study was done..negative An echocardiogram was performed....negative 10/19/19 around midnight the patient had severe pain in his back again and went to the ER. This time a chest x-ray did reveal a blood clot in the lungs. He was sent home with a prescription for tramadol. Over the next several months he was sent to a neurologist, a pulmonologist and a rheumatologist. As of 1/18/20 all tests including test for autoimmune disease were negative. However, he is still on blood thinners. He also has had to go to physical therapy he has trouble with walking/balance, possible nerve damage.