Age: 34.0
Sex: M
Vaccine: COVID19
Symptoms: C-reactive protein increased, Computerised tomogram abdomen abnormal, Cryoglobulins, Decreased appetite, Fatigue
Clinical narrative: The patient is a mechanical engineer that came 8 years ago to attend graduate school.  He had since moved and works as a mechanical engineer.  The patient has previously been quite healthy with exception of some elevated blood pressure readings which he states run in his family.  He has not been seeing a doctor on a regular basis. He reports no previous significant bowel issues.  Patient states that he was in his usual state of health until 4 days ago when he got his second dose of Pfizer Covid vaccine.  He reports the following day he did develop low-grade fever.  Yesterday he reported that he felt almost completely back to normal with slightly decreased appetite and just feeling weak and run down.  This morning he woke up with epigastric and bilateral upper quadrant abdominal pain associated with nausea.  He vomited several times what appeared to be stomach contents without blood.  He was evaluated at nearby urgent care center and from the referred to the emergency department.  In the emergency department work-up is positive for moderately elevated blood pressures (only slightly above baseline), mildly elevated blood blood cell count of 11,000, normal platelet count and normal renal function electrolytes.  Urinalysis showed only trace of protein. CT scan abdomen pelvis was obtained which showed acute celiac axis vasculitis involving the celiac artery, proximal hepatic artery, splenic artery.  He was found to have large geographic area hypoechoic attenuation involving the spleen compatible with acute ischemia. After contacting rheumatology he was given dose of Solu-Medrol 125 mg intravenously.  Patient was also given injection Lovenox subcutaneously.  We are asked to see him for admission.  Patient denies any headache, difficulty with vision, cough, difficulty breathing, hemoptysis.  He reports no difficulty with bowel function. Patient has rash on the extensor surface of both legs but he reports this rash has been there for a long time and he felt that this was likely sequela from scratching his legs after falling (rash appears consistent with psoriasis). Patient reports no recent history of international travel in July, 2019.  He traveled between May 3 and 6 this year.  Reports that he has been quite diligent about wearing a mask and denies any sick exposures and known Covid exposure. Patient has never used tobacco.  Drinks beer infrequently and in moderation.  He is married, has no children.   Patient was maintained on Solu-Medrol 125 mg every 8 hours for 2 days.  He was initially started on clear liquid diet and diet was gradually advanced.  He was seen in consultation with vascular surgery anticoagulation was recommended to prevent clotting of the affected vessels.  Patient was maintained on Lovenox throughout the hospitalization and will be discharged on Xarelto.  Abdominal symptoms completely resolved.  Interestingly his sedimentation rate is normal and C-reactive protein is only mildly elevated.  ANCA and ANA serology came back negative. Cryoglobulins are pending.  Case has been discussed at length with rheumatology.  He will follow the the patient closely after discharge.  He will see the patient next 7 days.  Please note that we did search to vaccine registry for similar cases of vasculitis after Covid vaccine.  Were able to find only two reported cases but neither of those fit the presentation of this patient?one had ANCA associated vasculitis and the other one was IgA mediated appears to have skin manifestation which this case does not appear to have.  Bottom line is patient has medium vessel abdominal vasculitis which may or may have not been related to his Covid vaccination.  Likely will require gradual weaning of steroids with close monitoring.  He will remain under care of rheumatologist and vascular surgeon after discharge.  The plan at this point is to repeat his abdominal CT scan in 4 to 6 weeks and decide if to discontinue anticoagulation at that time.