Age: 20.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Altered state of consciousness, Arthralgia, Axillary pain, Blood folate normal, Blood pressure increased
Clinical narrative: After first vaccine: History: Moderna COVID vaccine on 3/11/2021. Arm soreness over the first day or two but nothing else that really struck her. A few days after she started to notice axillary pain that progressed up her right neck and down to her right hand. She saw a physician who thought she was having nerve pain brought on by the vaccine. Around the 18th she started to feel a snapping pain in her wrist. Went to ED on the 20th because she started to have arm shaking, she was given ativan, her arm shaking stopped and they discharged her home. That evening her fingers felt clenched. On the 21st she woke up in the morning, went to urinate and dropped to the floor because her legs felt like jello and felt like they kept giving out. They initially thought the ativan was just making her feel out of it. They waited until the evening but then needed to go to the ED. The concern was GBS and transverse myelitis. They ate dinner and decided to drive to ED, on the drive she was kind of falling asleep periodically. Then she suddenly couldn't lift her water bottle. She started to be completely out of it, Mom says she wasn't responding. Pt says that she felt like she knew what was going on, felt a little out of body and wasn't quite responding. Mom couldn't get her out of the car, she was carried into the ED and at that point she started to recover a little bit more. About 10 minutes later she started to feel better. She was admitted because she was still having trouble walking. In the hospital she had a normal CT head and video EEG but she didn't have any events while on the monitor. Discharged home the following day with the diagnosis of functional neurologic disorder and instructions to establish care with an adult PCP. They advised considering CBT as well.  Since discharge her legs feels tired, going up the stairs feels much harder than it should. She has not had any falls and no longer feels like she is going to fall.  She follows with a therapist, has had dissociative episodes and panic attacks in the past.   Assessment:  20 YOF with PMH of panic attack, POTS, IDA and benign heart murmur who developed weakness of b/l LE and altered consciousness approximately 10 days after her first dose of Moderna COVID vaccine. Also had an episode of unilateral arm shaking the day prior that resolved with ativan in the ED. At this point unclear if directly related to vaccination. Differential includes mild Guillain-Barre 2/2 previous infection or vaccination, stress reaction/anxiety, POTS complication, myasthenia gravis, tick bite, infection, heavy metal poisoning, B12 deficiency, seizure disorder, atypical migraine. Functional Neurologic Disorder diagnosed by neurology after overnight admission  for video EEG which captured no events. CT head  also WNL per neurology discharge summary. Neurologic exam today WNL.   After Second Vaccine: History: She had her 2nd vaccine on 4/15 (6 days ago). Had vaccine in right arm again, she did have some arm pain again. She had coffee without breakfast in the morning. Had finished her first virtual class, went to the restroom during her second class, felt strangely in the restroom, went back to her room. She then passed out. Her fall was unwitnessed. She called to her roommate when she came to but her roommate hadn't heard the fall. She thinks she was only out for a few seconds but cannot be sure. Called her Mom who advised her to eat something so she ate an orange sitting on the floor. She got up to make herself breakfast and she passed out again. Again unwitnessed but patient thinks it was very fast. She crawled over to the couch, sat on the couch for for 15 minutes then felt fine for the rest of the day. She did not feel nauseous at all. She denies palpitations, difficulty breathing and chest pain.  Today in office after orthostatics and blood draw she fainted again, only out for seconds. BP elevated immediately after the event but WNL minutes later.  These syncopal episodes reminded her of her syncopal episodes with IDA and POTS. They do not feel like the episode after the first vaccine when she lost feeling in her legs and was very out of it.  She feels like her arm pain from the first vaccine never fully resolved. After the arm pain worsened from the 2nd shot she tried a 3 day course of aleve to see if that helped things. At this point it is mostly just her right wrist that is painful. Overall feels more localized to wrist than prior. She has since stopped the aleve, last was last night. She has not noticed redness or swelling in wrist or arm.  LMP was 4/2-4/6. She went almost a year without menses so stopped her OCP, but her menses have returned recently and she has restarted OCP.  Assessment: Right arm pain persisted from the first vaccination but otherwise sx had resolved. She got 2nd vaccination on 4/15, only arm pain but yesterday had 2 brief syncopal events and one today in the office. Orthostatic BPs not completely convincing for orthostatic hypotension today.