Age: 15.0
Sex: M
Vaccine: COVID19
Symptoms: Antinuclear antibody negative, Brain natriuretic peptide normal, C-reactive protein normal, CSF myelin basic protein, CSF oligoclonal band
Clinical narrative: Patient is a 15 year old M with hypofibrinogenemia, platelet aggregation disorder and history of COVID admitted to Inpatient Ward from 26 June - 01 July for work-up and management of new onset and severe headache, photophobia, and pain with extraocular movement. Extensive work-up complete but still unclear etiology, though near complete resolution of symptoms with IV steroids.   Neuro: CSF positive for HHV-6, still unclear if this fully explains presentation. CT and brain MRI negative, though limited exam due to braces artifact. Headache complicated by clear post-LP postural headache, though this improved throughout hospitalization, with nausea moderately controlled on Benadryl. Neurology and Ophthalmology consulted, who both thought peri-neuritis was plausible, which is consistent given such rapid improvement with steroids. Pain moderately controlled with Tylenol. Oligoclonal bands and MBP CSF studies pending at time of discharge. Plan for 7-day steroid taper as an outpatient (outlined below in patient instructions), and Neurology follow-up in about 1 month.  ID: Initially empirically covered with Ceftriaxone and Acyclovir, but once negative CSF, both were discontinued. He remained afebrile throughout remainder of hospitalization, so no further antibiotics started. Had remote history of immunodeficiency (confirmed here to be IgA deficiency), underwent more extensive immune work-up with lymphocyte subset 6 pending at time of discharge.   Fen/GI: Nausea and poor PO intake secondary to headache and neurologic symptoms. Unremarkable KUB with no focal findings on exam. Tolerated good liquid PO intake prior to discharge, improving food intake with help of Benadryl and Reglan (Zofran did not help his nausea). Given risk of Reglan side effects, trial of Benadryl alone was given and relieved his nausea.  Will discharge with Benadryl PRN for nausea, though expect this to improve.    Heme: No blood transfusions required, no history of recent bleeding/trauma, no signs of active bleeding. Received TXA for three days following his LP performed on 6/28.  Rheumatology: Patient has preexisting appointment with Rheumatology scheduled on 7/9 due to a history of intermittent joint pain/swelling with skin color changes since April 2020. Ordered requested Rheumatology labs by Doctor while patient is admitted. CRP and ESR resulted normal at 0.31 and 8 (respectively), C3 and C4 within normal limits, dsDNA and ANA negative. Repeat ESR on 6/30 also normal at 10. Pending labs include fecal procalcitonin. Follow up appointment with Rheumatology on 7/9.   CV: Some concern for myocarditis at time of presentation given pleuritic chest pain, history of COVID-19 infection, and recent COVID-19 vaccination. EKG at that time revealed nonspecific T wave changes. However, troponin and BNP resulted negative and patient's chest pain has resolved at this time. Discussed with Cardiology who did not think further work-up was necessary. Chest pain completely resolved at time of discharge.