Age: 42.0
Sex: M
Vaccine: ANTH, TYP, ANTH, TYP
Symptoms: Antiacetylcholine receptor antibody, Antinuclear antibody negative, Blood calcium decreased, Blood chloride normal, Blood creatinine normal
Clinical narrative: 42yo M who developed gradual onset of bilateral arm shakiness/tremor, decreased strength, headache, fatigue within days after immunizations for Typhoid and anthrax on 11/28/2017. He was seen by his doctor 6 days after immunization and found to have bilateral hand weakness on exam, referred to Local Neurologist for evaluation and brain/c-spine MRIs, labs obtained. Local Neurologist reviewed MRIs (brain MRI on 12/5/2017 showed "numerous scattered white matter subcortical increased T2/flair signal densities within the predominantly frontal lobe and to lesser extent the upper frontal parietal junction regions" and C-spine MRI on 12/12/2017 showed "mild degenerative changes at C4-C5 and C5-C6 that efface the ventral CSF space and narrows the central canal." Nerve conduction study/EMG on 12/8/2017 showed "changes in left deltoid and bicep muscles that are nonspecific but may represent residual changes from a previous left cervical (C5, C6) radiculopathy given the absence of active denervation. Rest of study is unremarkable." There was concern by the Neurologist about possible Parsonage-Turner syndrome (brachial neuritis) or neuralgic amyotrophy - he ordered a brachial plexus MRI (done 12/21/2017 and was wnl) and repeat brain MRI with contrast. Generalized symptoms resolved and arm symptoms became isolated to the left arm only. Patient continued to complain of left arm weakness and pain. He was treated with an oral steroid burst (12/14/2017), sent to Physical Therapy. He had mild improvement in symptoms but symptoms persisted. A 2nd EMG was done on 1/17/2018 which showed "mild neurogenic changes without active denervation at the left biceps and deltoid muscles that are nonspecific but may be related to residual changes from a previous cervical (C6) radiculopathy." Gabapentin was ordered. Patient also had CSF studies done on 2/2/2018, only report from those studies is that no malignant cells were found. Patient was eventually seen at a tertiary center (on 9/17/2018 ) where patient reported that his original symptoms included weakness of left arm with numbness/tingling, decreased feeling in his fingers. He reported improvement in overall symptoms but still 40% decrease in his usual strength. On exam their note states his 'motor strength in the left upper extremity was 4/5, and sensory exam showed hyperesthesia and decrease in cold sensation in the left upper extremity.' The neurologist's impression was that patient had: "signs and symptoms consistent with left brachial neuritis, probably related to vaccine. Recommended to continue PT. IVIG is an option that may expedite recovery. For pain suggested LYRICA, CYMBALTA or ELAVIL." They ordered various labs and wanted to repeat his brain/c-spine and brachial plexus MRIs before proceeding with IVIG treatment. The repeat MRIs did not show any new findings, his repeat EMG done on 10/8/2018 states 'there is electrodiagnostic evidence of left mild and chronic C6/C7/C8 radiculopathy without ongoing denervation.' Patient did also see a neurosurgeon on 10/2/108 whose note states that his cervical spine did not appear to be producing his numbness and tingling that were occurring in his left upper arm. He received IVIG Jan 13-18, 2019 and started to have hot/cold flashes and burning sensation in his left shoulder radiating down the arm. He was subsequently treated with LYRICA which did seem to help.