Age: 60.0
Sex: M
Vaccine: COVID19
Symptoms: Full blood count, Gastric emptying study, Gastrointestinal examination, Globulin, Glomerular filtration rate
Clinical narrative: worsening Autoimmune Rheumatoid Arthritis; abdominal distension; Recurrent Covid 19 Pneumonia; constipation; symptoms of obstruction/ Recurrent severe GI symptoms of obstruction; Iatrogenic Cushing's Syndrome; If I have a meal I often "pass-out" immediately after; severe abdominal pain; the development of hemorrhoids; he developed cellulitis in his upper left thigh at an injection site; osteoarthritis; He developed rectal prolapse while trying to move his bowels; He had a single drink, then developed amnesia and bizarre behavior for the next 18 hours; developed more red spots and rash all over my body; a rash developed on both arms within a few hours/ a total body rash and welts occurred; Skin sloughing of the arms occurred; Left kidney stone; hydronephrosis; Tears in left achilles tendon and peroneus brevis; A left knee superficial bursa fistula; Addison's disease, with pituitary, adrenal and gonadal dysfunction; Upper Respiratory infections including Bronchitis; Pneumonia; severe right scapular pain radiating to the chest wall/ a rash appeared with vesicles/ Shingles; developed fever; chills; injection arm became painful; injection arm became painful, erythematous, and twice the size of the left arm; erythematous; arthralgia; myalgia; This spontaneous case was reported by a physician and describes the occurrence of RHEUMATOID ARTHRITIS, PSEUDO CUSHING'S SYNDROME, ABDOMINAL DISTENSION, CONSTIPATION, INTESTINAL OBSTRUCTION, COVID-19 PNEUMONIA, PNEUMONIA, ADDISON'S DISEASE, HYDRONEPHROSIS, TENDON RUPTURE, FISTULA, LOSS OF CONSCIOUSNESS and NEPHROLITHIASIS in a 7-decade-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 prophylaxis. The occurrence of additional non-serious events is detailed below.    Co-suspect product included non-company product Semaglutide (Ozempic) for HbA1C.    On 27-Jan-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. In February 2021, received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) dosage was changed to 1 dosage form. On 17-Jan-2022, received third dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) dosage was changed to 1 dosage form. On 30-Jul-2022, the patient started Semaglutide (Ozempic) (unknown route) .25 milligram once a week. In January 2021, the patient experienced PAIN IN EXTREMITY (injection arm became painful), PERIPHERAL SWELLING (injection arm became painful, erythematous, and twice the size of the left arm), ERYTHEMA (erythematous), PYREXIA (developed fever) and CHILLS (chills). In 2021, the patient experienced RHEUMATOID ARTHRITIS (worsening Autoimmune Rheumatoid Arthritis) (seriousness criteria hospitalization and medically significant), ARTHRALGIA (arthralgia) and MYALGIA (myalgia). On 24-Aug-2021, the patient experienced HERPES ZOSTER (severe right scapular pain radiating to the chest wall/ a rash appeared with vesicles/ Shingles). In 2022, the patient experienced PNEUMONIA (Pneumonia) (seriousness criterion medically significant) and BRONCHITIS (Upper Respiratory infections including Bronchitis). In 2023, the patient experienced PSEUDO CUSHING'S SYNDROME (Iatrogenic Cushing's Syndrome) (seriousness criteria hospitalization and medically significant), CONSTIPATION (constipation) (seriousness criterion hospitalization), INTESTINAL OBSTRUCTION (symptoms of obstruction/ Recurrent severe GI symptoms of obstruction) (seriousness criteria hospitalization and medically significant), ADDISON'S DISEASE (Addison's disease, with pituitary, adrenal and gonadal dysfunction) (seriousness criterion medically significant), TENDON RUPTURE (Tears in left achilles tendon and peroneus brevis) (seriousness criterion medically significant) and FISTULA (A left knee superficial bursa fistula) (seriousness criterion medically significant). In July 2023, the patient experienced HYDRONEPHROSIS (hydronephrosis) (seriousness criterion medically significant). On 11-May-2024, the patient experienced RASH (developed more red spots and rash all over my body). In May 2024, the patient experienced SKIN EXFOLIATION (Skin sloughing of the arms occurred) and URTICARIA (a rash developed on both arms within a few hours/ a total body rash and welts occurred). In 2024, the patient experienced NEPHROLITHIASIS (Left kidney stone) (seriousness criterion medically significant). On 17-Sep-2024, the patient experienced COVID-19 PNEUMONIA (Recurrent Covid 19 Pneumonia) (seriousness criteria hospitalization and medically significant). On 11-Nov-2024, the patient experienced RECTAL PROLAPSE (He developed rectal prolapse while trying to move his bowels). In November 2024, the patient experienced AMNESIA (He had a single drink, then developed amnesia and bizarre behavior for the next 18 hours). On an unknown date, the patient experienced ABDOMINAL DISTENSION (abdominal distension) (seriousness criterion hospitalization), LOSS OF CONSCIOUSNESS (If I have a meal I often "pass-out" immediately after) (seriousness criterion medically significant), ABDOMINAL PAIN (severe abdominal pain), HAEMORRHOIDS (the development of hemorrhoids), VACCINATION SITE CELLULITIS (he developed cellulitis in his upper left thigh at an injection site) and OSTEOARTHRITIS (osteoarthritis). The patient was hospitalized from 17-Sep-2024 to 20-Sep-2024 due to ABDOMINAL DISTENSION, CONSTIPATION, COVID-19 PNEUMONIA, INTESTINAL OBSTRUCTION and PSEUDO CUSHING'S SYNDROME.  The patient was treated with Crestor, Coq10, Acthar, Lidocaine, Semaglutide, Olumiant, Prednisone, Hydrocortisone, Z-pak , Benadryl, Zovirax, Dulcolax, Vitamin d, Magnesium, Lorazepam, Mounjaro) Testosterone, Phentermine, Bupropion, Furosemide, Dhea, Calcium, Milk of magnesia, Lasix, Mvi, Vitamin K, Stonehenge health dynamic mushrooms, Melatonin Tirzepatide, LInzess, Meloxicam, Flurinex, Valacyclovir, Reclast, Colace, Xifaxan, Glucophage. PAIN IN EXTREMITY had resolved. In 2021, PERIPHERAL SWELLING and ERYTHEMA had resolved. In September 2021, HERPES ZOSTER outcome was unknown. In October 2024, FISTULA had resolved. At the time of the report, RHEUMATOID ARTHRITIS, PSEUDO CUSHING'S SYNDROME, ABDOMINAL DISTENSION, CONSTIPATION, INTESTINAL OBSTRUCTION and ABDOMINAL PAIN had not resolved, ARTHRALGIA, COVID-19 PNEUMONIA, PNEUMONIA, ADDISON'S DISEASE, HYDRONEPHROSIS, NEPHROLITHIASIS, BRONCHITIS, SKIN EXFOLIATION, HAEMORRHOIDS, VACCINATION SITE CELLULITIS, OSTEOARTHRITIS, URTICARIA, PYREXIA, CHILLS, MYALGIA and RASH outcome was unknown, TENDON RUPTURE, RECTAL PROLAPSE and AMNESIA was resolving and LOSS OF CONSCIOUSNESS had resolved.     For mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown), the reporter did not provide any causality assessments.  He was in his usual state of good health, taking no medications on a regular basis until Jan-2016. Patient denied any history of hypertension, diabetes, myocardial infarction, CVA, peptic ulcer disease, etc. In Dec-2017, patient started a slow taper of the Prednisone to eliminate this medication. Quick tapers in the past led to significant painful symptoms and were not successful. Beginning at that time the dose was reduced 1mg every 3-4 days. As of 01-Jan-2018 he was taking 6mg daily in the morning. Furthermore, he had a 5.5-hour infusion of Remicade to potentially decrease the Rheumatologic side effects and to assist with the steroid taper. Patient's medical history also included symptoms of neurogenic bowel, and multiple orthopedic injuries.  In 2018, his joints hurt; all his muscles were weak. He was unable to raise his right arm laterally due to pain in the deltoid region, and a spontaneous hematoma of the right biceps appeared without trauma, turning the entire arm ecchymotic. Weakness developed in both hands, and incredible disabling fatigue. Doctor recommended resuming higher dose. On 01-Mar-2018, the entire set of symptoms increased and ultimately by 05-Mar, he was quadriparetic. Patient was admitted from 05-Mar to 07-Mar-2018. Discharged on high dose steroids (prednisone 60mg daily). Remicade was halted, and Actemera was prescribed. He was admitted for cardio-pulmonary issues on 07-Apr-2018. Between 07-Mar to 07-Apr-2018, the medications were followed diligently, but new symptoms appeared- severe muscle spasms in both hands with the slightest of intentional activities. The extremity muscle pain/weakness persisted, and developed increasing difficulty dressing, going up and down stairs, and performing fine motor activities. He also developed constant dizziness/nausea, a sense of imbalance, more severe respiratory distress. He was brought to the urgent care center to rule-out a cardiopulmonary event. From a cardiac perspective he had an EKG and echocardiogram to rule-out myocardial infarction, congestive heart failure, etc. On 10-Apr-2018, he was discharged on high dose Prednisone (again), antibiotic prophylaxis (Bactrim DS, 1 tab three time weekly), an increased dose of Actemera (162mg weekly instead of biweekly), two inhalers including a long-acting steroid inhaler and an Albuterol rescue inhaler. The Actemera did not lead to any improvement in the Autoimmune RA. From a diagnostic perspective the cell count was very high, consistent with an inflammatory arthritis. From therapeutic perspective steroids were injected into both knees. Over the subsequent three months the rheumatologic medications were altered. Patient took Humira and Methotrexate (MTX) every seven days. Patient was able to reduce the steroids from a dose of 60 mg daily in Jan-2018 to 3 mg daily in Jul-2018. Starting in mid-Jun-2018, patient began experiencing mid-spinal pain without any accompanying neurological symptoms. This pain was in the thoracic region and when severe it caused posterior rib pain in the region with deep breathing. There was no numbness or weakness in the upper or lower extremities. Doctor felt that these symptoms were not necessarily related to inflammatory arthritis. Since patient took steroids continuously for more than two years, she was concerned about steroid induced osteoporosis and fracture. The pain on the evening of 13-Jul-2018 was much worse. Patient required several doses of oral narcotics. Patient's concern was this sudden onset of pain and spinal compression was due to the use of catabolic steroids continuously leading to bony changes in the spine. Osteopenia/Osteoporosis was diagnosed. On Labor Day weekend he developed worsening muscle and joint symptoms. The muscular symptoms were consistent with the flu. All his joints became painful. On Saturday evening of that weekend his bilateral knee pain increased significantly. After attending a dinner, he was unable to walk. The pain persisted and NSAID's were not effective. During the subsequent 72 hours the pain continued, requiring narcotics. Both knees developed effusions and the right knee was triple the size of the left. Doctor recommended increase Prednisone to 20 mg daily, increase the MTX to 20 mg weekly and bilateral knee aspirations. Whereas the aspirate from both knees was highly inflammatory consistent with an Autoimmune process. Patient developed severe URI/Cough/Bronchitis and was treated with Cefuroxime. The situation improved, but not completely. From Jun-2018 to Jul-2018, he developed worsening Spinal and Thoracic pain with no numbness or weakness of upper or lower extremities. From Oct-2018 to Nov-2018: Migratory joint symptoms continued including shoulders, wrists, knees elbows and ankles. A reduction in steroids from 5mg to 3mg daily was not tolerated. The Prednisone was increased to 5mg again and the MTX was increased to 25mg weekly on 03-Nov-2018. This led to severe abdominal pain and fatigue. On 05-Nov-2018, he developed dyspnea, wheezing and a cough. He was placed on Cefuroxime and the steroids were increased. Three doses of Humira and MTX were held during this episode. On 03-Nov-2018, this increased dose of MTX led to severe fatigue and abdominal discomfort. Humira was taken on 04-Nov-2018 and the symptom complex worsened. On 05-Nov-2018, patient developed dyspnea, wheezing and a cough. This situation worsened. He was evaluated and treated by his Pulmonologist. He was placed on Cefuroxime (500 mg BID x 10 days). Due to his immunocompromised status, it was recommended that he increase his steroids temporarily. The weekly Humira and MTX were held during this episode as these medications can lead to worsening of the Pneumonia. A total of three doses of Humira and MTX were held. Patient felt well during this hiatus and was able to exercise without difficulty. On 06-Dec-2018 he restarted the Humira as the joint symptoms reappeared. Within 12 hours he developed a rash, myalgias, joint pains (knees, elbows, hands, and back), and welts. The welts disappeared with a dose of Prednisone (20mg). However, the subsequent 24 hours were horrible with an increase in flu-like symptoms. The flight was extremely cold, and the flu-like symptoms were much worse on the flight. He was unable to ambulate at the airport and required a wheelchair to retrieve his luggage. He was unable to sleep Friday night due to pain and on Saturday morning the facial rash and welts reappeared. He spoke with the covering Rheumatologist and restarted MTX (10 mg). This led to NO improvement in symptoms. On Monday doctor recommended an increase in steroids. Patient took 20 mg Monday (10-Dec-2018) at night and was able to sleep and felt better in terms of muscle and joint symptoms. The persistent discomfort was in the region of the right humerus and deltoid regions. Patient remained off Humira and MTX from early Dec-2018, but as a result the Prednisone was increased from 5 to 10-20 mg daily, dependent upon severity of symptoms. Despite the joint symptoms he exercised nearly every day between 26-Dec-2018 and 14-Jan-2019. During that three-week period a bigger problem was related to voiding, abdominal pain and abdominal distension, an increase in size of the abdominal wall hernia and alteration in bowel habits. He denied any BPR but did have constipation. This had been a problem since commencing Keytruda. He took several types of cathartics with variable success, and at times had symptoms of an ileus, with abdominal distension, tenderness at the hernia site, and increased voiding symptoms. 06-Dec-2018: Humira was restarted due to an increase in joint symptoms. Within 12 hours of this SQ dose he developed multiple joint pains, swelling in the knees, a rash followed by large welts all over body. The welts disappeared with a 20mg dose of Prednisone. He was flying home. By the time the flight landed he was unable to walk due to joint pain, myalgia, and flu-like symptoms and was transported via wheelchair through the airport. The covering Rheumatologist suggested trying a lower dose of MTX (10mg), which led to no improvement in the condition. Developed pulmonary symptoms, which led to hospitalization in Mar-2019.  Patient also had what appeared to be an infected cyst on the left cheek, which had not resolved in over 8 weeks. On 14-Feb-2019, two days after taking his weekly MTX, his joint symptoms suddenly increased and bilateral knee effusions redeveloped (right greater than left). His upper respiratory infection returned and was treated simply with OTC medication. On 19-Feb-2019 doctor re-evaluated him, aspirated 35-40 mls. of fluid from each knee and injected steroids. The knees subsequently improved. Steroids were injected into the site. In mid-February, the respiratory symptoms worsened. He was given a Z-Pak as well as a cough suppressant with codeine. A temporary increase in Prednisone was also recommended (20 mg BID). This produced no significant improvement and therefore his Rheumatologist was consulted and Levaquin (500 mg daily), a decrease in the steroid dose, and halting the MTX was recommended. As of 11-Mar-2019 the following symptoms persisted- constant shortness of breath and sensation of wheezing, severe fatigue, infected rhinorrhea, constant cough and chest discomfort with infected appearing mucous, constant dizziness and intermittent headaches, constant flushed face without being in the sun and diffuse abdominal pain. On 22-Mar-2019, he had supposedly had a follow-up appointment post hospitalization with a Pulmonologist. That morning his O2 saturation was 96% upon awakening, room air. With nebulizer therapy it increased only 1%. Patient also noted a significant increase in the left flank ecchymosis, the appearance of a petechial rash on his back and chest wall, and another significant ecchymotic region in the perineum extending posterior to the gluteal muscles and anterior to the mid-thigh and bilateral inguinal regions (suggestive of a pelvic bleed). He was advised to slowly continue the steroid taper (1.0 mg per week), with the goal of eliminating this medication. If successful, the MTX and TNF Inhibitors would also be eliminated thereafter. Upon returning he developed identical upper respiratory symptoms again, including constant shortness of breath, intermittent wheezing, rhinorrhea, constant cough, etc. He consulted doctor and a five-day course of Zithromax was ordered. Doctor was also consulted, and she recommended holding both Methotrexate and Simponi. The rhinorrhea improved but the asthma-like symptoms persisted: cough, respiratory distress, and wheezing. Patient had been slowly decreasing the Prednisone to 3 mg daily with no worsening of the joint symptoms. However, due to the respiratory distress he had to increase the Prednisone to 5-10mg qd or bid. At night he was often unable to lie down without severe respiratory distress. The last dose of Simponi was administered on 01-Apr-2019. The last few times he took MTX he developed several days of severe abdominal pain. He was unable to eat without nausea, vomiting, or diarrhea. This occurred twice within 12 hours of taking the medication. Between 09-May and 16-May-2019, his physical stamina deteriorated. He slept at least 3-5 hours in the late afternoon, every day. He had a constant feeling of flu-like symptoms that was all his muscles ached constantly. He experienced chills every afternoon. Doctor evaluated him thereafter, and recommended continuing the Simponi, not the MTX. The joint symptoms in both knees improved on 10-Aug-2019, whereas, the hand and wrist symptoms persisted, but were tolerated. Patient had nuclear gastric emptying study to evaluate possible gastroparesis, and neurogenic small and large bowel.  On 10-Nov-2019, he developed daily episodes of flu-like and migratory arthritis symptoms. Motrin, Advil, or Excedrin were utilized around the clock for knee, quadriceps, hand and wrist pain with bending, etc. He awakened every night feeling septic. Bilateral knee effusions redeveloped, and bilateral LE lymphedema. Every day he was extremely fatigued and required multiple-hour naps. Development of recurrent severe joint and skin manifestations of Autoimmune RA in April and May-2020. Some improvement in joint pain with the use of Plaquenil between Mar-2020 and Sep-2020. Intermittent severe exhaustion during July and Aug-2020 requiring multiple hour naps during every day. Several discussions were partaken regarding the potential use of Sirolimus or Chemotherapy as the next step. Patient felt better with the oldest oral medication, compared to all other medications, namely Plaquenil. He has basically experienced no side effects; whereas the other two courses of treatment have deadly side effects and were far more complicated. During October and Nov-2020 the knee pain somewhat improved and was tolerable most of the time. Unfortunately, the pain and weakness in the fingers, hands, wrists and forearms increased significantly. Severe fatigue was always omnipresent. Possible gastroparesis and neurogenic bowel dysfunction in 2020-never confirmed on any radiological studies. He also used steroids which produced the typical side effects of weight gain (over 45 lbs.), muscle loss. When the steroids were reduced, the rheumatologic and fatigue related symptoms were unbearable. He utilized NSAID's again initially without increasing the steroids. None of them were helpful. He woke up at night in severe pain and this necessitated an additional dose of 5-10 mg of Prednisone daily. A significant amount of fluid was removed bilaterally (60 mls/side), and Medrol was injected into each knee simultaneously. Doctor also suggested a "lubricant", such as Synvisc in the future. After this procedure the pain and knee swelling improved. Ambulation became less bothersome. In terms of symptoms, he continued to experience back pain, but this like many other pains was tolerated out of necessity. He continued to experience migratory joint symptoms especially the shoulders, greater than the wrists, then the knees, then the elbows and ankles, in that order. He tried to decrease the steroids (down to 3 mg per day), whereas the Humira and MTX remained on the same weekly doses. Unfortunately, the reduction in steroids was not clinically feasible and the dose of Prednisone was kept at 5 mg daily, the MTX was increased to 25 mg weekly. In Jun-2019 Patient experienced multiple dental issues. He fractured a tooth, requiring a Root Canal and reconstruction. He also required two Wisdom Teeth extractions. Due to persistent tooth and jaw pain a CT of the Jaw was performed. This showed no evidence of fracture or abscess. It was performed due to the complications associated with Osteoporosis secondary to prolonged steroid use and the use of Fosamax. As of Sept-2019, the repaired teeth remain painful to touch, but the situation is being tolerated. Patient was able to return on 09-Jul-2019 for one month. He was determined to improve his physical status, and all the deterioration produced by the Prednisone and other drugs. He exercised many hours daily (swimming, weightlifting, biking and golf). He lost 18 lbs. in 18 days with this regimen and simultaneously decreasing meal intake (high protein low carb diet). The problem from an RA perspective has been severe knee pain and swelling, episodes of myalgias, arthralgias, and flu-like symptoms. His knees were aspirated in early June (60 mls. on the right and 40 mls. on the left) and Medrol was injected bilaterally. The effusions reappeared in two weeks. On 7/7/19 repeat aspirations were necessary (40 mls. on the left and 60 mls. on the right). At that time Synvisc was injected bilaterally and a lower dose of Medrol. Exercise was recommended to "move" the lubricant throughout the joint spaces. With the weight loss the Sleep Apnea disappeared. Patient had a Simponi Infusion on 06-Aug-2019. He tolerated this for 24 hours but then developed transient respiratory symptoms, increased myalgias and arthralgias. Doctor evaluated him on 07-Aug-2019 and felt that the left-sided Adenopathy was not clinically significant and required no biopsy or node dissection, etc.  Due to the exacerbation of symptoms with the first IV infusion of Simponi at 200 mg, patient requested a decrease in dose for the second infusion. It had been necessary to take Motrin and Excedrin every evening to diminish the chills; otherwise, he would never be able to sleep. Knees and quadriceps were especially painful, and in the AM, it was very difficult to bend my knees. His hands and wrists were more affected than previously. Every afternoon between 10 and 18-Nov-19, Patient would pass out from fatigue. He awakened late every night with the feeling of "being septic": myalgia, arthralgia, chills, etc., which only partially resolved with 400-800 mg of Advil. Significant effusions redeveloped in both knees, right greater than left, as well as bilateral LE Lymphedema. Bilateral knee aspirations and injected Medrol simultaneously was performed. 70 mls was removed from the right and 40 mls from the left. That evening he had no septic symptoms and the following morning he felt much better. His conclusion was that this episode was a flair of the Autoimmune RA and a reaction to the IV infusion. On the morning of 09-Feb-2020, he attended a brunch with six people. Within an hour of the meal, he developed significant abdominal distension. No one else became ill. He was admitted from the ER. The nausea, vomiting and diarrhea halted. He was at bowel rest for 24 hours; a surgical consult was obtained to rule-out a surgical abdomen, given history of a recurrent abdominal wall hernia and RLQ pain. Blood cultures were presumably negative. He was discharged on 12-Feb-2020 in improved condition. However, between 12 and 18-Feb-2020 he was unable to advance diet. He ate soup and once or twice tried solid food. The latter caused distension, pain, and passed a minimal amount of gas. The pain remained diffuse, and he always had a sensation of impending N+V or desire to move bowels but could not. Between 20 and 22-Feb multiple cathartics were utilized sequentially until it led to a massive amount of bowel movement. This included three Dulcolax tablets, then 24 hours of MiraLAX continuously, followed by one bottle of Magnesium Citrate and ultimately one ounce of Lactulose. The distension disappeared after the bowel movements. However, the distension, tympany, and pain returned on 23-Feb and remained on 24-Feb. In the morning of 24-Feb, a GI consultation was obtained. He had hypoactive bowel sounds, significant distension and pain especially at the site of the recurrent hernia. On 28-Feb-2020, patient was evaluated. Doctor believed that the TNF inhibitors may be contributory to recent symptoms and stopped them. Prednisone was not eliminated. On examination, he had significant bilateral knee effusions. Doctor aspirated both, performed a cell count, and injected steroids. He experienced daily waves of severe joint and muscle pain, a sensation of fever and chills, all of which he experienced throughout Keytruda therapy. Physician believed that the recurrent hernia could not lead to severe symptoms, but it should be repaired electively via a laparoscopic approach with mesh. Simultaneously the abdomen should be examined for adhesions, etc. He scheduled an upper endoscopy and colonoscopy for 09-Mar-2020, to rule out common etiologies. Future treatment would be predicated upon the findings of these two operative procedures. Ingestion of normal food was attempted the day after the procedure, and this led to severe abdominal pain and distension again. On 11-Mar-2020, he was awakened with continued abdominal pain and distension along with welts and hives on trunk and extremities. He took usual medications added Claritin. The rash disappeared in several days. Patient was able to eat small meals without gastric distension or a feeling of bowel obstruction. Bowel habits were not normal. If he did not move his bowels within several days, he became distended in the lower abdomen and required a combination of MiraLAX powder and Dulcolax tablets. Patient did not perceive the sense of bowel fullness or the desire to move his bowels on most occasions. The cathartics took 24-36 hours to be effective and then they produced diarrhea. Comparatively speaking, this set of symptoms was far superior to continuous bowel distension and pain, which he perceived in the past as possibly SBO. Nonetheless, patient usually ate only one meal per day and did not tolerate more, or "heavier" foods. He was unable to bend his right elbow to brush his teeth, pick up a cup and drink, or take a pill. The right biceps were painful and became more atrophic. He was unable to sleep on his right side because pressure on the right arm was very painful. There was no numbness to suggest a neurological cause. In terms of medications, his last infusion of Remicade proceeded on 30-Jan-2020, after which the four hospital admissions occurred. In terms of Prednisone, it clearly remained essential. On Tuesday 07-Apr-2020, he inadvertently forgot his morning dose for the first time in three years. That evening every joint and every muscle group became extremely painful. He was also significantly fatigued. He had not felt this bad from a joint or muscle perspective in several years. The following morning, he realized this situation and took 10mg of Prednisone upon arising and 5mg in the evening with improvement in all his symptoms. The muscle and joint symptoms exacerbate when the bilateral knee infusions increase. In April he was taking 10mg of Prednisone daily, but increased this when the effusions reappeared. Doctor performed bilateral aspirations on 20-Apr-2020. Furthermore, he was placed on Plaquenil 200mg BID. Despite the complexity of the situation and the degree of symptoms, he was much happier and in less pain than when he had severe bowel symptoms, distension, and the possibility of a surgical bowel obstruction. Between 05-May and 28-May-2020 the abdominal distension steadily decreased, tolerance of normal foods improved and bowel function slowly improved. Constipation remained, however. On the other hand, he developed massive welts, erythema, skin exfoliation, and increased bruising throughout his entire body in mid-May. It was extremely painful. He initially thought this was related to Plaquenil, and thus halted it. He had no reduction in the welts or worsening of joint symptoms for 48 hours. Then he began to experience worsening muscle and joint pain. He took several doses of Motrin and the rash increased within fifteen minutes of each dose. Thus, he believed the Motrin was the culprit not the Plaquenil. Patient was unable to walk without assistance on 15-May-2020.  Doctor aspirated both knees in June and July. Doctor examined him and obtained lab data. Patient considered Rituxan, but ultimately decided to continue Plaquenil since the side effect profile was miniscule, and the continuation of Prednisone far less dangerous than the chemotherapeutic agent Rituxan. On 03-Sep-2020 he had an interval skin check, and several small lesions were frozen, but no melanoma was suspected.  Patient tried to halt the Prednisone and the Plaquenil for the two weeks between 31-Aug-2020 and 15-Sep-2020. For the first week he had absolutely no significant symptoms. By the end of the second week however, he was extremely fatigued, and his hands began to hurt again. On 15-Sep-2020 he took 5mg of Prednisone and 400mg of Plaquenil. This reversed his symptoms within several hours. Patient continued the Plaquenil (400mg qd) and Prednisone (10mg qd) since that time. During Oct-2020 and Nov-2020, he had- nearly constant fatigue, increased pain and weakness in fingers, hands, wrists and forearms, persistent constipation and intermittent orthostasis which correlated with tamsulosin. Patient had 9 years of intense follow-up scans, including MRIs (Brain, T and LS Spines), CTs (chest, abdomen, pelvis), inguinal ultrasounds, laboratories, etc. Prednisone, Solumedrol IV, oral Medrol dose packs, etc., had been utilized continuously since Jul-2017. Joint injections of Medrol had been utilized for seven years also. He had received recurrent bilateral knee effusions requiring numerous aspirations and steroid injections (approximately 45 sets of bilateral aspirations) between 2017 and 2024. Patient had hives, welts with Enbrel. Welts and skin exfoliation, and increased skin bleeding with Advil liquigels on multiple occasions in May-2020; this resolved. Positive for DOE, chest muscle discomfort in 2017-2018 resulting in hospitalization; Positive for chronic right and left pedal edema, right greater than left due to radical LN dissection. Within several hours of Moderna vaccination, the injection arm became painful, erythematous, and twice the size of the left arm. This was treated with Benadryl (50mg), Prednisone (10mg) and Advil (400mg). All muscles and joints ached. The left arm was very painful for 3-4 days and was unable to lie upon the left side. He developed fever, chills and it felt like a recurrence of COVID-19. He took high dose steroids with a five-day taper. The pain in the arm lasted for two weeks. The arm swelling and eryt