Age: 83.0
Sex: M
Vaccine: VARZOS, VARZOS, VARZOS
Symptoms: Central nervous system lesion, Lumbar puncture normal, Nuclear magnetic resonance imaging spinal, Sensory disturbance
Clinical narrative: 01/30/2019 History of my "numbness". History of present problem: 12/26/2018 SHINGRIX Rx followed by 2 days of severe lethargy and diarrhea. Early January 2019 - bowel evacuation?, oddity? - I did think there was some numbness in the perineum at that time. Week of 1 January -awoke one AM with bilateral sole of foot numbness (no paresthesias). I thought this was some type of peripheral neuropathy. 11 January - appt. with Dr. (cardiology); noted somewhat low BP so rec. I dc LASIX 10 mg. EKG was normal. 15 January - saw Dr. who was concerned of caudal equina syndrome; numbness now up to ankles and lower legs (R greater than L); and definite perineum. There has NEVER been any pain or muscle weakness since the beginning of problem. Blood sugar normal at Dr's. office. MRI ordered. Rec. I see Dr. (neurosurgeon) at hospital. 18 January - MRI of lumbar spine and sacrum at facility. 19 January - told MRI showed no tumor but severe foramina narrowing on R on at least 3 levels; numbness now up to lower thighs. 22 January - saw Dr. (neurology) no Dx made! I did make an app't. with Dr. (neurosurgeon) at BI for 31 January. 28 January - lumbar epidural by Dr. at Medical Center; no improvement in Sx after 48 hours. Got approval for epidural from Dr. office. 31 January - saw Dr. at hospital; said surgery on foramina narrowing definitely not indicated. Questionable Dx of small fiber sensory neuropathy but said I needed a thoracic MRI. 6 February - MRI of thoracic spine w/o contrast at location. 7 February - Dr. called; MRI showed definite abnormality at T4 cord level. 8 February - MRI read as 21 mm x 4 mm x 2 mm abnormal cord signal at T4; possible Dx's = demyelinating disease, transverse myelitis, prior infarct, sequelae of prior inflammatory or infectious process; neoplasm not excluded. Had results of MRI sent to Dr.'s office. 8 February - saw Dr. (neurology) at Hospital in PM. Films reviewed; felt that transverse myelitis was a probable Dx and could account for my symptoms; also said that this could be a reaction to SHINGRIX vaccine. Rec. extensive blood work; LP; MRI w/contrast of affected area as well as MRI w/wo contrast of cervical spine and brain. 9 February - Dr. called me in CT. Discussion of above eval. wants to review MRI, and report and will follow up with me and Dr rec's. 11 February - MRI w/wo contrast of thoracic spine at location. In AM saw Dr. in PM; discussed work up; blood tests ordered and arrangements for MRI of neck and head w/wo contrast at hospital. I felt that definite improvement in Sx. i.e. perineum numbness all but gone and thigh numbness better as well as feet R greater than L. 12 February - blood drawn at lab. 13 February - told that all blood test were ok, including Hemoglobin A1C; vit. B12; serum folate; Lyme antibody screen; and C-reactive protein. 14 February - Head and neck MRI w/wo contrast at Hospital; told no evidence of demyelination in brain or cervical cord. Lumbar puncture to be arranged soon; hopefully the end of testing. 21 February - LP at Medical Center - done in X ray without incident - 4 vials - 8 cc. 22 February - Dr. called - spinal fluid normal as was pressure; Dr. might like cardia, aorta ultrasound to R/O possibility of infarct; also to have follow up dorsal spine MRI in future to note changes. Definitely better re-symptoms; almost back to "normal". 26 February - some esoteric spinal fluid tests done at Clinic were normal. 1 March - Dr. called; said no reason that ultra sound of heart of aorta would yield any useful results (as per Dr.) therefore "testing done!" 5 March - essentially back to "normal" save some residual decreased sensation when having a bowel movement - but control is ok. About 10 weeks after onset of first symptoms. 18 March - saw Dr.; "case" discussed and will have repeat MRI of dorsal spine sometime (ca 6 wks or so) to finalize this "incident".