Age: 22.0
Sex: F
Vaccine: COVID19
Symptoms: Insomnia, Intensive care, Lumbar puncture, Magnetic resonance imaging head, Magnetic resonance imaging spinal abnormal
Clinical narrative: Around the 5th of May, 2021, Pt felt a numbness sensation in her right hand that radiate it up her arm. 1 week later, the numbness presented in her left hand as well following by a tingling. The numbness and tingling wrapped around her chest making it difficult to breath. Pt was taken to the hospital and went into the ER. They misdiagnosed her with a Pulmonary Embolism. Pt started to feel excruciating neck pain which cause an inability to sleep during this time. The doctors decided to do an MRI scan of her cervical spine. The doctors saw that she had lesions on her spine. The treatment in the hospital was blood thinners for the misdiagnosed Pulmonary Embolism and a low dose steroid as well for the inflammation of her spine. 10 days after Pt was admitted into the hospital. Once at hospital, Pt was admitted into the ICU. The staff did an MRI of her brain, cervical and thoracic spine, and a lumbar puncture. That's when the doctors diagnosed her with Transverse Myelitis. Here are some notes from the Doctors, "22 year old female without significant past medical history  who was transferred to center for further evaluation of right upper extremity numbness and weakness. Here, the patient underwent completion MR imaging which confirmed a large, vertically extensive cervical cord lesion, and a lumbar puncture. The patient was started on pulse methylprednisone with marked improvement of her right upper extremity symptoms. The patient has a very large lesion involving the majority of the cervical cord. The main differentials are a significant demyelinating event and malignancy. Covid19 vaccination. Of note, patient received the Johnson & Johnson...If this ends up being a demyelinating event, this probably should be reported." Medications given at center are Tylenol 325mg PO 2 pills every 6 hours for headache.  CARBAMAZEPINE XR 100mg PO 1 tab twice a day for spasms due to working diagnosis. Enoxaparin 40mg/ 0.4ml x 0.4ml syrn injected underneath skin daily for misdiagnosis of PE by the doctors (discontinued due to Doctors reasonable conclusion that there was no CLOT whatsoever.) SOLU-Medrol 1g IV daily. Pt was then MEDEVAC to different enter on the 27th of May, 2021. Pt was hospitalized at center for 4 days with follow up appointments for Occupational therapy, physical therapy, Immunology, Hepatology. Pt felt the same symptoms such as Numbness and weakness in right hand, tingling sensation in left hand digits, spasms and tremors. The Doctors note reads, " Patient with evidence of primarily central T2 hyperintensity spanning greater than 3 vertebral segments in both cervical and thoracic cord with corresponding right upper extremity mono-paresis and sensory changes to multiple modalities... The highest suspicion was for an autoimmune etiology such as NMOSD." Previous medications that were given at previous center were discontinued and the new medications are as follows: predniSONE 20mg PO with tapering of steroids included for Transverse Myelitis. Gabapentin  300mg PO 1 pill twice a day for nerve pain. PROTONIX 20mg PO 1 tab everyday for GI protection due to steroids being harsh on the stomach Tylenol 325mg PO take 2 tabs every 6 hours PRN for pain. Rituximab 1g IV. Pt flew back to her home on the 9th of July, 2021. During this time till now she has been feeling the same symptoms as described before. Numbness and weakness still in her right upper extremity, painful spasms, inability to sleep, left upper extremity beginning to show weakness as well. Through all these events it is without a doubt that this has taken a toll on her body, both physically and mentally. Pt while here at home station saw a civilian Doctor named Dr. who is rheumatologist. He was taking up the decision whether to allow the second dose of Rituximab for Pt. He did his own exams and wrote his own notes apart from the military providers. He questions whether Pt has NMOSD or MOGAD. In his notes he questions whether there is a relationship between this acute illness and the J&J vaccine. I, a (spouse), write this from Center as Pt and I sit here because of another ER visit due to worsening symptoms. She is currently waiting to be discharged from the hospital. She received another treatment of steroids IV to combat the inflammation of her spinal cord with another MRI being taken on Friday the 30th of July 2021. The MRI showed a new lesion on her cervical spine which was behind the reason of her intial visit to the ER, neck pain. I believe the J&J vaccine triggered something in Pt body to cause this disorder to arise prematurely. Of course the question is when was it supposed to happen? I wrote this because she told me she did not feel right two hours after the J&J vaccination was administered to her. With the recent news articles of J&J vaccine and the side effects of GBS or Guillain-Barre syndrome appearing, I knew this report had to be made. I thank you for your time for reading this report and please feel free to contact me.