Age: 62.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: C-reactive protein normal, CSF protein increased, CSF white blood cell count increased, Computerised tomogram abdomen normal, Computerised tomogram head normal
Clinical narrative: Narrative: Patient was in his baseline state of health until 4/6 when he noted R hemibody numbness, which began with right-sided facial numbness when brushing teeth. He was evaluated by his PCP (no exam noted) and initiated on regimen of doxycyclnine 100mg BID, acyclovir 800mg TID, and prednisone 40mg for 'Bells Palsy'. On 4/9, a referral to neurology was made after pt returnedd to clinic w/ burning deep low back pain that radiates up to his shoulder, and his b/l temples. Neuro exam documented at that time denote a L sided Bells Palsy only. CBC, CMP, PSA, RPR, TSH, B12, ESR, CRP, RPR, Iron lvls were all normal. MRI brain and Lumbar spine were ordered and pt was to obtain expedited LP. Pt again re-presented to urgent care on 4/12 due to severe burning back pain that resolved w/ activity. At this time again only L sided facial weakness noted (documented as reduced ability to close eyelid, raise eyebrow, weakness puffing out cheeck, and reduced smile on L), no other weakness, drift, or sensory findings. Pt was instructed to continue doxycycline 100mg BOD 10d course (4/6-4/15), prednisone 40mg 7d course (4/6-4/12), acyclovir 800mg TID 7d course (4/6/-4/15), prednisone 40mg 7d course (4/6-4/12), acyclovir 800mg TID 7d course (4/6-4/12). Pt was instructed to obtain MRI and LP in expedited fashion. Telephone note Addendum on 4/14 noted improve in Bell Palsy symptoms and back/shoulder/head pain w/ tylenol. Given persistent back pain and J&J COVID19 vaccine, pt was instructed to present to urgent Care. He deferred until the following day. On 4/15 pt woke up w/ worsening facial numbness. He presented to urgent care w/ b/l inability to close eyes and 'when attempting both eyes roll up into his head . He also complained of sharp pain upon extending his RUE and RLE. Exam showed b/l inability to close eyes, description of Bells phenomenon, and palpable tenderness at base of C spine w/ mild spasms. CTH was obtained and was unremarkable. CT C spine showed multilevel degenerative cahgnes w/ neuroforaminal narrowing at C5-C7. Given inability for pt to obtain an expedited MRI and LP to r/o inflammatory or malignancy process at outside hospital case was discussed and accepted for transfer on 4/15. Of note pt obtained J&J vaccine on 3/18 by outside hospital. On presentation patient confirms the timelime detailed above and additionally notes that he has lost his sense of taste. Pt underwent MRI scan on day of admission 4/15/21 which showed enhancement of the bilateral facial nerves and oculomotor nerves, and possible trigeminal nerve enhancement. He underwent LP which showed 6 WBCs and 346 protein;negative cytology and flow cytometry. Given his clinical presentation and imaging/CSF findings, high suspicion for atypical GBS/AIDP which EMG done on April 20th, 2021 was most consistent with. He underwent CT C/A/P which were all negative for malignancy. He was treated with IVIG for presumed AIDP/GBS. Discharged on April 21st, 2021.