Age: 5.0
Sex: M
Vaccine: COVID19
Symptoms: CSF white blood cell count negative, Chronic inflammatory demyelinating polyradiculoneuropathy, Culture negative, Cytomegalovirus test negative, Demyelination
Clinical narrative: 12/4/21: 2nd dose of Pfizer Covid vaccine 12/23/21: FIrst symptom of LEFT sided ptosis (did not resolve) 1/13/22: Noticable worsening of LEFT ptosis 1/23/22: Limping began  1/24/22: Limping worsened with LEFT leg splinting (knee pointed inwards) 1/26/22: Presented to PCP; labs obtained:  WBC 9.4 (37N, 55L), H&H 14.2/41.9, Plts 274. ESR 2, CRP <1.0. Glu 84, cr 0.38, AST 33, ALT 17. Left lower extremity XR done and showed a "cortical irregularity of the left femoral head".  1/29/22: Presented to ED: Pelvis XR showing LEFT femoral head flattening and irregularity, possible AVN vs benign variant. Ortho consulted and felt consistent with LCP.  ***PLEASE SEE PAGE 2 FOR CONTINUED TIMELINE*** 2/3/22: Seen at clinic  was unable to bear weight, had a positive Gower's sign prompting non-con spine MRI which was normal.  2/4/22: Seen by Neuro for LEFT sided headache, LEFT eye ptosis and LEFT leg weakness; referred to ED and admitted.  2/4/22  2/11/22: Admitted for progressive LEFT sided weakness. Brain MRI showed diffuse cauda equine nerve root thickening and enhancement (greatest ventrally) and mild leptomeningeal enhancement circumscribing the conus; all suggestive of an acute inflammatory demyelinating polyradiculopathy (AIDP, GBS). Labs showed WBC 6.9, Hct 31.7, Plts 188; ANC 1173; ESR 19, CRP <0.8. Blood cultures from 2/7/22 were negative. LP done on 2/5/22 which showed CSF WBC 2, RBC 1, Prot 263, Glucose 50; Albumin 162.0, Synthesis Rate 32.43, IgG 17.4, IgG/Albumin Ratio 0.11, IgG Index 0.73. CSF Mycoplasma PCR neg. CSF cultures were negative. He received IVIG 2/5/22  2/7/22 which was subsequently complicated by symptoms of aseptic meningitis.  2/11/22  2/18/22:  Transferred to inpatient rehab, where he showed improvement by the time of discharge.  3/1/22  3/5/22 Admitted to hospital again due to gradual decline in LE strength to point of not being able to sit or walk independently. CIDP started to rise higher on the differential. Toto received another round of IVIG 2g/kg over 2 days  had again post-infusion reaction. Upon discharge had improvement in lower extremity muscle function.  4/4/22  4/7/22 Re-admitted to hospital due to worsening ascending weakness, and new progress nausea / headache in morning, worsening of his ptosis (which had never completely resolved since first appearing on 12/23/21) and blurry vision. He was found to have increased ICP and papilledema on brain MRI; notably, no evidence of demyelination of brain or brainstem. MRI head venogram was normal. Had an LP confirming increased ICP with opening pressure 26-42; WBC 26 (0% polys, 100% other cell types), RBC 2, Prot 150, Glucose 138.  CSF viral PCR panel negative (CMV, HSV, HHV6, ENV, Parecho, VZV PCRs). Culture negative. Elevated WBCs and Protein thought to be secondary to prior IVIG treatments and high protein supportive of CIDP diagnosis. Received IV Methylpred 30 mg/kg from 4/5-4/7. Started on Acetazolamide.   4/16/22 - Continues to follow with Neurology and Rehab / Therapy