Age: 62.0
Sex: M
Vaccine: COVID19
Symptoms: Magnetic resonance imaging head abnormal, Migraine, Nasal congestion, Nausea, Neck pain
Clinical narrative: DEVELOPED RAMSAY HUNT SYNDROME WITHIN ONE WEEK OF THE BOOSTER SHOT.  SEE ATTACHED MEDICAL BACKGROUND FOR PATIENT FOR SYMPTOMS, TREATMENT, PRESCRIPTIONS, IMPACT ON DAILY LIFE AND ABILITY TO WORK, AND RELEVANT CONTACT INFORMATION FOR PHYSICIANS, HOSPITAL, REHABILITATION CENTER, MEDICAL DIAGNOSTIC CENTER AND PHARMACIES.  Patient is 63 years old and has worked continuously for over 45 years as an auto mechanic. He was laid off from his job at the end of October 2021 due to the pandemic and was planning to actively look for a new job. However, in December 2021, he contracted Ramsay Hunt Syndrome. a neurological disorder, which many believe was triggered by the COVID-19 Moderna booster shot which he had received just a week earlier.  As a result, he has been to the emergency room twice, was hospitalized once, took medications to treat his condition which were largely unsuccessful, participated in vestibular and occupational therapy, and has been under the care of a neurologist. Despite his strong desire to return to work, he is unable to do so given the serious and ongoing nature of his medical condition.  Symptoms: His symptoms include the following: Facial palsy/paralysis of left side of face Left eye cannot close by itself and doesn't blink Severe pain in left and right eyes Foggy or blurred vision in both eyes Experiences flashes of light when he closes his eyes Dry eyes and mouth Tinnitus or ringing in left and right ears Severe pain in left and right ears Severe pain in both ears radiating down to neck and shoulders Cannot exhale through left nostril or blow his nose when congested Diminished dexterity and coordination of hands, especially the right hand Shaking of both hands Severe headaches/migraines almost daily Fluctuating blood pressure/hypotensive episodes during the day Lightheadedness, dizziness and vertigo (with room spinning), especially when getting up from bed or changing his position Very unstable on feet when standing and walking Loss of balance which results in frequent falls Chronic fatigue, lack of energy and feeling tired all the time Shortness of breath upon exertion Cold hands and occasional low oxygen levels Insomnia due to symptoms Oversleeping due to lack of sleep Nausea Vomiting Diarrhea Hallucinations  Chronology of Illness and Treatment 11/29/2021 Received Moderna Booster. Previously received Moderna vaccine on 4/17/2021 and 5/15/2021. 12/6/2021 Experienced onset of symptoms one week later. Severe pain in left ear and dizziness 12/13/2021 Developed facial palsy and vertigo. Went to the Emergency Room at Medical Center. Performed CT scan to rule out stroke. Preliminary diagnosis: Bell's Palsy. Started on antiviral (Valtrex) and oral steroids (Prednisone). Given a prescription for Antivert for dizziness (which did not work). Discharged from Emergency Room. 12/17/2021 Saw Primary care physician. Suspected a possible ear infection. Extended steroids another 6 days. Prescribed antibiotic (Ampicillin) and antibiotic ear drops. Recommended seeing an ENT physician and neurologist. 12/22/2021 & 2/2023 Saw ENT. Evaluated ears and ordered a hearing test. Did not find an ear infection. Hearing test revealed only a slight hearing loss in one ear but nothing remarkable. Recommended stopping the antibiotic and eardrops but continue with steroids until finished. Preliminary diagnosis: Ramsay Hunt Syndrome (without rash). Recommended seeing a neurologist and an ophthalmologist and scheduling vestibular rehabilitation therapy. Also suggested a MRI Brain/IAC with and without contrast. Follow up visit in 2/2023 for a hearing test due to difficulty hearing. 12/23/2021 Saw neurologist, who ordered an MRI to rule out tumor versus stroke versus bleed. Recommended a Lyme test and vestibular therapy if Ramsay Hunt Syndrome. Prescribed Valium for the vertigo which later worsened his dizziness and caused serious hallucinations. 12/24/2021 & 9/9/2022 Had MRI test which found neuritis. Had a follow up MRI to determine whether the situation had improved or worsened. Found evidence of microvascular ischemic disease. 12/26/2021 The covering neurologist discontinued Valium due to hallucinations. Started on Vistaril 25 mg BID (antihistamine). Was OK for a few days but then developed a severe headache. Doctor prescribed Fioricet, which subsequently led to further hallucinations, so Fioricet was discontinued. Doctor increased Vistaril to 50 mg BID. Vertigo only worsened so the medication was stopped. 12/13/2021 - 1/6/2022 Symptoms during this time: Vertigo got progressively worse, the room continued to spin and everything was upside down. Experienced ringing in the ears, sharp stabbing ear pain extending to neck and shoulder on the left side, and extreme sensitivity and pain to his outer left ear. Severe pain in left eye and unable to close left eye, thereby straining the right eye. In addition, he experienced severe headaches/ migraines, no appetite, nausea/vomiting, and difficulty eating and drinking due to palsy. Feet and outer two fingers on each hand also became numb. Intermittent sharp pain in various spots on upper chest and legs. 1/6/2022-1/10/2022 Was taken to the Emergency Room at Medical Center because he was in acute distress and believed he was dying. Was admitted to the hospital for observation and treatment. At the suggestion of his sister, who is a nurse, the attending neurologist scheduled IV steroids to combat the vertigo which eventually worked. Was discharged from hospital. 1/14/2022 Started vestibular therapy and occupational therapy. Therapy was later discontinued because he was too ill and was not improving. 1/17/2022 - Present Regular follow up visits with primary care physician. Due to taking steroids for the Ramsay Hunt, patient gained about 50 pounds and developed diabetes for which he is currently being treated. 1/25/2022 - Present Regular follow up visits with neurologist who determined that she could not do more to alleviate his symptoms or treat the disease. 2/2023 Visit to optometrist due to difficulty with eyes and sight. Found cornea abrasion. Referred him to a Neuro-Ophthalmologist.