Age: 63.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Blood bilirubin increased, Blood bilirubin unconjugated, Blood bilirubin unconjugated increased, Computerised tomogram normal, Hepatitis viral test negative
Clinical narrative: Patient is a pleasant 63-year-old gentleman who came to the hospital originally on 4/10/2021, refer you to the H&P done at that time by Dr. Comes in with a diffuse rash over his torso and his legs. He did get COVID vaccine, his first one (4/1/21 at Imaginetics) about a week to a week and a half before admission. He said shortly thereafter is when his symptoms began. The rash is pruritic. He had no breathing troubles whatsoever. No throat closing or tongue swelling, etc. No mouth lesions and in fact the rash over his torso and his back is pretty minimal, looks more like a sunburn type appearance. In any case, also had a petechial type of purpuric rash on his legs and I did show this to Dermatology who felt that it did look like vasculitis. He was placed on                                                                                                                                                                                                                      steroids. He did SOLU-MEDROL while here and this was converted to prednisone on discharge for which he will continue with for the next few weeks. Slow taper. Rash had improved over his stay here. His LFTs were also up somewhat as well, but these did improve while he was here and multiple imaging studies were done including ultrasound, CAT scan and abdominal Doppler all were negative for any kind of                                                        pathology. Suspect probably these elevated LFTs could have been from vasculitis and that is also improving now with the steroids. He is tolerating diet well. He has no abdominal pain. Okay to be discharged today.  We will continue with prednisone taper. Follow with PCP in 1 week. Also know, there is an ANA pending as further workup for                                                                                                                                                            vasculitis. We will defer to PCP on follow up for that.    4/21/21                                                                                                                                                       Follow-up with PCP: 63-year-old male here for a hospital follow-up. He was hospitalized for rash suspected to be vasculitis and elevated LFTs-started 2-3 days after his COVID vaccine. Etiology of elevated LFTs unclear. Liver US and CT were negative. Hepatitis, viral testing, and ANA negative. Received his first COVID vaccine on 4/1. Still on prednisone taper for rash. He is feeling better, still somewhat tired. Rash is almost resolved. Current complaints sore on the left side of his tongue for the past 11 days. Initially hurt when he would eat, is better now. Is back at work. Denies abdominal pain nausea, vomiting, stool changes, dark or light stools, yellowing of skin, swelling in abdomen or legs. Does not use tobacco, alcohol, or drugs. No history of liver issues. Normal LFTs 7 months ago. Follow up appt at Allergy/Immunology on 4/29/21: Plan: Patient had a delayed reaction to his 1st dose of Pfizer vaccination that included symptoms of arthralgias, rash as well as elevated liver enzymes.  His symptoms don't meet criteria for type 1 IgE mediated reaction so skin testing would not be beneficial.  His symptoms required hospitalization and improved with tapered steroid course.  His symptoms did not fit DRESS syndrome criteria as he did not have peripheral eosinophilia, fevers, sloughing of skin/oral mucosa or blistering.  We discussed how there is not much data or case reports about how to proceed with completing vaccination for COVID.  I would recommend he get Johnson & Johnson vaccination since it is a different class of vaccine and he may not have the same reaction but again this is not guaranteed.  There is a small chance of clotting with Johnson & Johnson vaccine as well.  He should pre-medicate with cetirizine 20 mg po qday for 1 week before vaccination and 2 weeks after.  I would also suggest he get a steroid course to have on hand from his PCP in case rash starts again after vaccination.  It may be beneficial to have him get lab work several days after vaccination as well (U/A, CBC, CMP) to evaluate for any inflammation.