Age: 59.0
Sex: F
Vaccine: COVID19
Symptoms: Rash, Red blood cell sedimentation rate increased, Rheumatoid factor increased, SARS-CoV-2 test negative, Skin discolouration
Clinical narrative: Patient arrived at ED 05/03/2021 with slurred speech, left-sided facial droop, left leg weakness.  Per discharge summary by MD : Before January 2021 pt was quite healthy and working in a casino.  On January 15, she fell in the parking lot and was started on Ibuprofen (800 mg) and flexeril for pain control.  On mid-February pt received COVID vaccine and about 1 week afterwards she developed dyspnea on exertion associated with night sweats, poor appetite, dry cough.   She had multiple workup done in the clinic including PCR-SARS-COVID x 2, which on both occasions were negative.  She was found to have elevated inflammatory markers including ESR and C-reactive protein.    She subsequently presented to ER the first time on 3/23 and found to be febrile with temperature of 39.3, saturation of oxygen was 100% on room air.  She had a repeat PCR-SARS-COVID.  This is her third one, which was negative.  She was found to have elevated levels of RF,  ANCA, markedly elevated CRP (>150).  She had (B) temporal artery biopsy that was negative.  She was discharged with oral prednisone 20 mg a day.   When she seen by Dr of rheumatology in clinic a few weeks later, her prednisone was increased to 60 mg a day for 2 weeks, then reduced to 50 mg a day.   She presented back to the hospital (this admission) on 5/3/21 with slurred speech, left facial droop, and LLE weakness and left foot numbness.  MRI brain showed acute infarct of left corona radiata though Dr of neurology reviewed the MRI and felt that there is some abnormality in the right temporal region as well, which would explain pt's neurologic symptoms.   She was placed on aspirin and high-dose statin (LDL was 132).  Usual stroke workup was negative.  She was maintained on prednisone for her recent dx of vasculitis.   She subsequently developed severe pain of her left flank and subsequent eruption of a dermatomal rash, consistent with shingles.  She was started on Valtrex 1 g three times daily.  She was also started on neurontin with uptitrating doses.   She had persistent pain so Lidoderm patches were tried which improved her pain significantly.   Initially there was consideration of rehab placement though pt improved to a point that she was felt appropriate to discharge home.  However, pt's daughter, who would be caring for patient at home, is 6-month pregnant, and worried about pt's shingles and the risk of transmission.   Therefore pt was not discharged home but rather kept in the hospital on Valtrex with ongoing attempts at placement.  Pt ultimately finished 7-day of Valtrex.  The vesicles on her left back have all flattened and the area now is mostly a nearly confluent region of dark discoloration.   At this point we re-discussed with pt's daughter that since pt has finished a 7-day course of Valtrex and that her vesicles have resolved, there is extremely low risk of transmission, especially with standard hand-washing hygiene at home.  Pt is also quite independent at this time and would not need assistance from her daughter for ambulation/ADL.  Pt will also have her own room at home.  At this time, pt's daughter and family were agreeable to take patient home.   In retrospect, pt's "vasculitis" symptoms appear to have started in earnest about 1 week after she received her COVID shot (1st shot, she never received a 2nd shot due to severe symptoms) so it is possible that her vasculitis may have been caused/triggered by COVID vaccine.  Other possibilities (less likely) include high-dose Ibuprofen (though she took lots of this in 2010 after another fall) or flexeril, though the timeframe is a bit longer.   In any event, she was advised to avoid unnecessary medications, particularly NSAIDs and flexeril at this time until her clinical picture becomes clearer.  She should also never receive COVID vaccine again.