Age: 70.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: C-reactive protein normal, Carbon dioxide normal, Fatigue, Feeling hot, Haematocrit normal
Clinical narrative: 70 y/o female of Asian descent developed a mild, pruritic, hive-like rash on her left arm and leg about 2 days (21 Jan 2021) after receipt of her 2nd BioNTech vaccine (injected in her left arm; no other vaccines given on that day). Patient did not self-treat. Rash continued on 26 Jan when patient was evaluated in Medical Center  ER  described as "3 small wheals located on left upper and lower extremity with excoriations"; she was treated with Benadryl 25 mg orally and the itching decreased and the rash significantly diminished. No other signs or symptoms concerning for allergic reaction. Patient also reports onset of muscle aches, starting within 48 hours of vaccine receipt; also reports onset of fatigue, headache, and feeling hot.  The headache and feeling hot resolved within 72 hours, but fatigue and muscle aches continued. Reports muscles hurt in her arms legs, and chest.  Around 22 Jan, patient began having diffuse joint pain in her extremities. The pain became significantly worse on Sun, 24 Jan. Patient self-treated with Ibuprofen with some relief. By 26 Jan, when patient sought evaluation at ER, she described the joint pain as "unbearable" and rated pain intensity as 9/10. In the ER, patient was afebrile and her exam noted: bilateral hand and wrist swelling (left>right), but no redness or warmth at joints; full ROM, but pain increased with movements. Diagnosed as reactive arthritis and prescribed Tiger Balm and Lidocaine patches, with continued Ibuprofen recommended.  At follow-up appointment with patient's PCM on 29 Jan, she reported continued muscle and joint pains. She reported some relief with topical analgesics and Ibuprofen, but Ibuprofen upset her stomach, so was changed to Celecoxib 200 mg twice daily as needed. Topicals and Benadryl were renewed. (Benadryl helped rash, but patient ran out and had recurrence of pruritic rash.) Muscle pain continued in her extremities. Reported fair control of muscle pain with topical analgesics and Celecoxib. Reported having "muscle spasms" in her hands. Patient reported increased sensitivity  painful sensation when she touched something cold. Reported using a pot holder to hold a cold can of soda to reduce pain.  Joint pain primarily in hands, wrists, shoulders, feet, ankles, and knees. Reported swelling of hands and wrists resolved after about 2 weeks. She also had swelling of her left foot, which resolved. Reported some relief of joint pain with topical analgesics and Celecoxib, but joint pain interfering with sleep. Patient's fatigue continued. Spouse describes as decreased stamina. An example:  they used to go out to do errands over a 2-hour period and it would not impact patient's energy level; now, after 2 hours of minimal-to-moderate activity, patient is exhausted.  Follow-up with PCM on 8 and 18 Mar 2021  rash resolved, but generalized muscle aches and joint pains continue.  No localized joint swelling. Full ROM. Labs ordered (see below)  patient's Rheumatoid Factor was elevated; she is pending a Rheumatology evaluation (appointment on 17 April). No history of recent trauma or injury. No previous history of similar joint pain. No history of arthritis or Rheumatic disease.   Not previously diagnosed with COVID and never tested positive for COVID; was quarantined in 2020 after returning from being on a cruise ship. After 1st COVID vaccine in Dec, she experienced a headache and local redness and tenderness at vaccination site, lasting less than 3 days.