History of present illness:
51 year old female who was seen at SLJ ER on 7/21/2020 with a 3 wk history of decreased appetite and generalized weakness and malaise. She had had prior colonoscopy and endoscopy showing only "mild colitis". She had been place on prednisone by her PCP. Her husband and daughter had recently tested positive for OVID 19 after separate trips to Mexico, but both had been essentially assymptomatic. An ultrasound of the abdoment was negative and CXR unrevealing. Her LFTs were initially elevated (SGOT 741 and SGPT 346, T. Bili 2.9). Her COVID 19 test was positive and was felt to be the cause of her symptoms and lab abnormalities. She was discharged home with appropriate instructtions for COVID19 symptom monitoring and self quarantine.
She returned to the ER on 7/25/20, unable to walk, with increasing weakness and numbness and loss of taste, with exam consistent with peripheral neuropathy. As before, she had no pulmonary symptoms. MRI of the C and T spine showed no cord compress, although there was some moderate to severe R NF stenosis at C5-6 and C4-5. MRI brain showed a small to moderate sized chronic left cerebellar hemisphere infarct and a small chronic R cerebellar and vermian infarcts.
She was admitted and treated with IV solumedrol for 3 days, with suspicion for an inflammatory polyneuropathy vs a paraneoplastic process. A lumbar puncture was benign, with normal cell count (2) and total protein (39). No improvement in the neurologic exam was noted and actually seemed to getting worse (legs 1/5 and arms 2/5 distally, stronger proximally). Decreased sensation in the LEs and depressed DTRs. She was hypophonic.
She was treated with a course of IVIG, with no definite motor improvement. She was treated with PLEX. No definite improvements noted.
She was treated with a 2nd course of IVIG 8/19/20, with minimal improvement noted only.
She developed a retroperitoneal hematoma on CT scan. She was diagnosed with DIC (disseminated intravascular coagulation). Diagnosed with anemia and was transfused.
A paraneoplastic panel was negative. SPEP negative for any monoclonal protein. Acute hepatitis panel was negative. ANA was 1:40. Negative alpha 1 antitrypsin, smooth muscle, and mitochondria antibodies.
She developed issues with encephalopathy/delerium and had hallucination. She says that she doesn't remember a lot about her acute hospitalization in the beginning. These symptoms were also attribuied to COVID19.
She had multiple electrolyte abnormalites which were replaced. Elevated lipase. Had AKI diagnosed and this has resolved. Treated with IV antibiotic for UTI
Her echocardiogram showed an EF of 34%, with some areas of hypokinesis, seen by cardiology with the impression of viral myopericarditis vs ischemic cardiomyopathy. She was treated for acute systolic heart failure.
She has not had an EMG/NCV test yet.
She was discharged to Brookdale SNF in Carmel Valley on 8/23/20. There she has shown some slow motor improvements in function, though still non-ambulatory, but felt now to be able to tolerate 3 hr/day of PT/OT. AFO's have been provided. Resolved DTI of the R heel. She has developed some painful nodules in the in the medial thighs bilaterally of unclear etiology. She has had multiple negative COVID 19 tests, the latest one last week. A repeat UTI (E. coli) has been treated with Keflex, completed 10/9/20. **On 10/13/2020 we admitted her to our ARU for rehab. She had the painful nodules to her medial and lateral thighs x greater than 3 weeks with no change in tissue color. on 10/14/2020 - I got a panic call from the nurse who was describing painful purple lesions to her rt thigh. Everyday she presents with more involvement and necrosis to bilateral thighs medial lateral and now lower legs. any thoughts.
Past medical/surgical history: As above. Hypoalbuminemia. Hypomagnesemia, on replacement. Anxiety (on bupropion). Mixed anemia. Fatty infiltration of liver. Left adrenal adenoma.
Cutaneous Vasculitis - Hemorrhagic skin necrosis- ?