36 Y male patient from another country with a past medical history significant for mild HTN (on 2.5 mg amlodipine) who was in his usual state of health until approximately 4/17/21 when he developed acute onset left volar forearm tingling sensation. He had received the Johnson & Johnson vaccine on 4/2/21 in his left arm and states that he did not experience any noticeable reactions after vaccination. He also recalls having had sustained a minor superficial scrape on his left volar forearm by a trash can lid when he had taken out garbage, which occurred very shortly before the onset of this tingling sensation. The tingling sensation then progressively worsened and became more diffuse across most of his body. He then developed fevers up to 102 at home, chills, neck pain, headache, and pain in all extremities (primarily arms but also in his legs).   He initially went to the Health Care ED on 4/28/21. He was afebrile at the time and his vital signs at that time were unremarkable with the exception of elevated diastolic blood pressures (90-104 mm Hg). WBC 10.1 with normal differential, electrolytes and liver enzymes within normal limits. Influenza, RSV, and SARS-CoV-2 PCR were negative. Urinalysis showed few bacteria but no WBCs. Chest x-ray was clear. Blood cultures were drawn and patient was then discharged.   Patient returned to the ED on 4/29/21 and reported fever to 102-103 d F, chills, nausea, weakness, body aches, and bilateral foot paraesthesias. He was afebrile (98.8) and his vital signs were within normal limits. His WBC was slightly elevated to 12.2 with a normal differential. His ESR was 11, CRP 1.5, CMP within normal limits. He was noted to have urinary retention and a foley was placed and he was given tamsulosin.    Patient then returned to the ED again the following day, on 4/30/21, with worsening generalized pain and weakness and difficulty walking.   ED course: temperature 101, heart rate 100s-110s, BP 140s-160s/70s-90s, RR low 20s, SaO2 high 90s. Labs remarkable for WBC 13.1 with 82.4% N, ESR 7, CRP 5.9, lactic acid 2.6, RF 10, urinalysis unremarkable, HIV antigen/antibody negative. Several imaging studies were performed. MRI T spine showed "Extensive cord signal abnormality in the cervical and thoracic cord as detailed above, with associated expansion of the cord (most pronounced in the cervical cord). Differential includes acute transverse myelitis, demyelination, infection (HIV, syphilis, other viruses)/parainfectious phenomenon, subacute combined degeneration, and inflammatory etiologies. An underlying mass or masses are not excluded but less likely given extensive multifocal patchy involvement. Recommend postcontrast imaging at this time for further workup. Consider brain MR as well to assess for systemic white matter disease."   A lumbar puncture was attempted in the ED but was unable to be performed.   Patient was given empiric IV ceftriaxone 1 g q24h and admitted to the hospitalist service. He was evaluated by neurology and was started on Solumedrol 1000 mg for acute transverse myelitis.   5/1/21 MRI brain showed "Multifocal patchy white matter signal changes, predominantly in the subcortical white matter, also present in the bilateral thalami and bilateral middle cerebellar peduncle, and redemonstration of extensive cervical cord signal abnormality and expansion. No associated restricted diffusion or enhancement. Broad differential, but given pattern of involvement findings are most concerning for ADEM (acute disseminated encephalomyelitis), other considerations include other demyelinating processes, toxic-metabolic pathology, or potentially atypical viral infection." Patient was given methylprednisolone for ADEM with transverse myelitis and clinically improved. He was hospitalized from 4/30/21 until being discharged to home in a wheelchair on 5/6/21.