Age: 89.0
Sex: F
Vaccine: COVID19
Symptoms: Bruxism, C-reactive protein increased, Carotid arteriosclerosis, Chest X-ray normal, Chest pain
Clinical narrative: She (reluctantly) received 1st dose moderna 7/30/21.  On Aug 3rd she felt dizzy and at times, pre-syncopal.  On Aug 4th, her dizziness worsened to the point that she had to walk by grabbing the furniture. That evening she developed L sided face and jaw pain, which improved with warm compresses.  However she didn't sleep that night due to pain.  Then on 8/5 the pain intensified so she went to ER where the possiblity of TA was raised (CTA head and neck was done; results summarized below); ESR/CRP elevated 72/4.9 (on scale to 0.9). She was given a single dose of pain med and prednisone 60mg and pain resolved; she has been relatively asymptomatic since then.  Though she still has some jaw stiffness.  No eye complaints. No rash. No fatigue. She has continued pred 60mg, which for unclear reasons she has been taking at bedtime and tolerting well.  She doesn't feel systemically ill or have fever/night sweats/fatigue. Specifically no PMR symptoms, though she does have curious pruritis over the nape of her neck. She did follow up with ENT on 8/6/2021, doctor who did not believe it was temporal arteritis but rather a severe case of TMJ due to teeth grinding.   Followed up with Rheumatology 8/13/2021: She underwent L TA biopsy 8/12/2021; results negative. She is currently pain free on prednisone 60mg daily x about 3 doses. My index of suspicion for temporal arteritis is high, though also on DDx is trigeminal neuralgia or impending shingles (she is s/p shingles vaccine relatively recently, though).  For now, will continue prednisone 60mg once daily while we await temporal artery biopsy results.  If positive, I would like to give her tocilizumab (every other week dosing, for at least 4-6 mo) as per GIACTA so as to spare her steroids and hopefully taper her off within 2-6 weeks.   On 8/16/2021: patient presents to the ED via EMS related to chest pain radiating to her back. CT angiogram of the chest revealed right-sided pulmonary embolism in the right lower lobe, apical segment.  Lower extremity Dopplers preliminarily showed no evidence of DVT.  She was started on intravenous heparin but shortly thereafter, she had significant hematuria and the anticoagulation could not be continued any further.   8/18/2021: Lower extremity Dopplers showed no evidence of DVT. IVC filter was inserted yesterday. CT urogram showed an apparent soft tissue thickening and possible circumferential narrowing at the right UPJ.  Urine cytology is pending. Urology has given clearance for the patient to resume anticoagulation.   General Imaging:    US Venous Duplex - Upper Extremity Bilateral  No evidence for DVT in the either upper extremity   CXR: No acute cardiopulmonary process.   CTA Chest With and Without IV Contrast  Pulmonary embolus involving apical segment right lower lobe   US Venous Duplex - Lower Extremity Bilateral  No deep venous thrombosis in either lower extremity.   CT Urogram With and Without IV Contrast  1.  Apparent soft tissue thickening and possible circumferential narrowing at the right UPJ.  Please correlate with urinalysis to exclude urothelial tumor. 2.  13 mm nonobstructing calcification lower pole calyx right kidney. 3.  No evidence of hydronephrosis.   Upon discharge from the hospital patient was started on Eliquis BID with the knowledge that this may lead to continued hematuria. She had also made the informed decision to not pursue any additional testing or exploration of the hematuria. She and her family were in agreement with plan of care moving forward.