Age: 27.0
Sex: F
Vaccine: COVID19
Symptoms: Complex regional pain syndrome, Computerised tomogram abdomen normal, Computerised tomogram head normal, Computerised tomogram thorax normal, Confusional state
Clinical narrative: Patient was healthy and well until she received the J&J vaccine May 5, 2021. No immediate reactions were noted until May 17, 2021 when she noted edema of her legs L>R. She actively run 5 and 10 K races without dyspnea or pain at the time and denied leg pain. One May 25, she came home for a medical exam; Edema was noted but no heart, lung  abnormalities were found or leg tenderness was absent. A Doppler sonogram of the legs and MRI of the knees were normal.   In late July, 2021 Patient experienced auditory, taste and visual hallucinations. She seemed agitated and talked incessantly. She expressed delusional ideation to her parents when she visited them  August 1-5, 2021. To her mother, a Child Neurologist, she appeared confused, anxious, with a severe tachycardia, dilated pupils, warm erythematous extremities and sweaty palms. In a local ER she had a normal Brain CT, TSH, Lyme, CBC and CMP. She expressed fear that her family might harm her. She was transported to a larger Hospital. During the trip she experienced frequent urination without dysuria, anorexia. She described early satiety and described a prior seven days of eating only flavored water. Complaints of thirst with habitual water drinking and polyuria occurred in late July and continued into her September psych hospitalization but would resolve when tests at the hospital required prolonged fasting. She developed constipation going 7-10 days with no bowel movement. During a 7 day hospitalization she was grossly psychotic. These episodes markedly worsened with in 15-45 minutes of eating a meal. Grossly feculent breath was noted after many meals but seemed to clear a 4-5 hours. In addition she demonstrated severe and recurrent postural tachycardia, incompletely improved by IV saline?s c/w Potts syndrome. 48 hour cardiac monitor revealed recurrent sinus tachycardia. Head MRI, CXR, CMP, CBCd, EEG, Chest and Abd CT, and lumbar puncture were normal. Multiple CNS markers for limbic encephalitis were absent. Attempts at longer term psychiatric hospitalization failed due to unavailable beds for admission. After multiple threats of self harm and continued paranoid ideation she was admitted to Psychiatric Hospital. She was given Seroquel but became angry and irritable. It was discontinued after 8 days.  A prior Lactulose Breath Test returned very positive and c/w  small bowel bacterial overgrowth. This prompted the start of Xifaxin 550 mgm tid. Simultaneously, a she was started on Lithium carbonate 300 mgm bid after a diagnosis of bipolar disorder manic type was made by multiple Psychiatry consultants. Within 48 hours of these two therapies, her affect and ideation returned to normal. No further hallucinations were noted. She expressed clear awareness of her prior hallucinations and faulty ideation.  Xifaxin was tapered to daily in November and stopped completely by 02/01/2022. Bid Lithium carbonate continues yielding low therapeutic blood levels of Lithium.  Several consultants believe that Patient developed a dysautonomia of the autonomic nervous system, i.e.,Gillian-Barre dysautonomia (Pott?s Syndrome, gastroparesis, small bowel bacterial overgrowth, hypomotility of the small and large bowel, and peripheral sympathetic dystrophy) and early limbic encephalitis with psychosis, manic type and that this followed the J&J vaccine. She remains clinically normal except for recurrent  asymmetric edema. of the L lower extremity.