Age: 61.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Impaired work ability, Inflammation, Influenza A virus test negative, Influenza B virus test, Influenza like illness
Clinical narrative: Prior to PfizerCV19 vaccinations: Overall very active and healthy - lifelong. Regular exercise for 70 min, five days per week including 20 min on elliptical at 50 RPM, could bike long distances, run, play basketball, paintball, etc. and keep up or exceed activity of teenagers (active youth leader for over 20 yrs.), frequent boating/fishing April through October. Own yard work and home construction and repair, including that requiring heavy prolonged activity. High activity endurance. Health issues: Known hypogonadism, BPH, and ED (prescribed Androgel). Known heterozygous Factor V Leiden (precautionary low dose coated aspirin). Had a kidney stone removed a few years ago. Superficial work on legs from Vein Clinics many years ago. Began taking men's multivitamin with extra vitamin D and zinc when COVID began. Still very active in 2020 with no issues. First PfizerCV19 vaccination, 15-Feb-2021 (Lot EL9265): No noticeable reaction. Second PfizerCV19 vaccination, 08-Mar-2021 (Lot EN6206): Within 3 to 4 days lower legs began wasting with significant skin purpling and blackish appearance in some places, began muscle weakness and sensory neuropathy in lower legs. This has not significantly resolved as of 1-Jan-2023. April/May through August 2021: Unusual daily fatigue and body-wide muscle weakness steadily increasing by the week. Muscle shakiness and a low-level tremor was slowly becoming noticeable as well as frequent GI upset. By August it felt like I had the flu constantly for months, but never had any congestion. I repeatedly tested negative for COVID by quick test and PCR throughout 2020/2021 and never had a fever or congestive infection from 2019 through to end of November 2022. I began to experience shortness of breath during the middle of this period with mild activities that would never give me this before; more pronounced when more active. I also became unable to tolerate alcohol during this period. Even one beer or glass of wine with dinner would make me ill such that I would have to sit down and sort of pass out with barely the ability to lift my head up for an hour or so. After recognizing the connection, I completely stopped beer/wine consumption, which was only moderate to begin with; 2-3 glasses total over a week's time. Recent testing' as of Dec 2022 suggests alcohol intolerance is not resolved, but I was also taking several medications by that point (prednisone, hydroxychloroquine, apixaban, Androgel). August through November 2021: Could no longer exercise or otherwise exert myself due to weakness, fatigue, unsteadiness, and shortness of breath with even mild exertion. Entire GI tract upset daily; not resolved until starting 16 hr. per 24 hr. intermittent fasting with keto dietary plan in Dec 2022. Constant swollen lymph nodes on back of neck and mild headache/brain fog had set in; not resolved until prescribed prednisone and hydroxychloroquine in second half of 2022. Significant daily fatigue and muscle weakness, noticeable body-wide shakiness and a low-level tremor felt throughout my body; shakiness/tremor not resolved as of 1-Jan-2023. Shortness of breath severely ramped up in the latter part of 2021 with some vague upper chest pain or tightness. Visited primary care again, Dr. on 24 Nov 2021  no resolution. Went to Urgent Care on 5-Dec-2021 and PCR tested negative for COVID, also tested negative for Influenza A & B, and by examination had no evidence of a congestive infection. However, the examining doctor said it seemed all my respiratory epithelial tissue had inflammation. I made my other symptoms clear to the doctor, presented as possibly vaccine induced. He did not address them at all and only told me to go home and take Tylenol for the tissue inflammation. I found Tylenol only gave temporary headache relief and was not a solution to the shortness of breath. Based on a medical article specific to this scenario, I then took 1000mg of vitamin C every 8 hours for 2 weeks, and the severe shortness of breath resolved back to manageable in 1.5 wks. I continue to take lower levels of vitamin C daily. I also found out as of Dec-2022 that an albuterol inhaler prescribed by a cardiologist (Dr.) provides additional relief, i.e., easier to breathe, allowing for daily recovery exercises that began in December 2022. December 2021 through early February 2022: Taking the extra vitamin C, alpha lipoic acid, and sometimes Tylenol, led to a plateau of symptoms in December and for most of January, but really didn't stop anything. Had to wear compression socks every day to reduce leg inflammation.  I tested negative for COVID by PCR again on 10-Jan-2022 in order to go in for work, but I had to stop going in to work shortly after due to near constant exhaustion. My primary care (Dr.) and immediate care physicians had no explanations for the occurrences mentioned above, even though I had expressed it was apparently a building vaccine reaction since I had received a second dose of the vaccine. On 27-Jan-2021 while working from home, I had a severe shooting pain from mid left back through the left shoulder and up the side of my neck. Emergency hospitalization showed bilateral pulmonary embolisms. This event required injections of low molecular weight heparin (or eq.), three days hospitalization, and subsequent apixaban treatment, 5 mg twice daily (still current). About a week after release, I went back to the emergency room because my GI tract had ceased movement/possible diverticulitis. I was again in severe pain, likely caused by the significant pain medication given in the week-prior hospitalization. Emergency room treatment and antibiotics got me back to my previous level of GI tract upset present after receiving the second dose of vaccine. My gastroenterologist, Dr., posited this could have been an aggravation of the possible vaccine reactions I was already having for some time at that point. March through June 2022: While in the hospital at the end of January, beginning of February, was told to stop taking Androgel (testosterone). I did so but by March my conditions of constant fatigue, muscle weakness/wasting, shakiness/tremor, shortness of breath, painful lymph nodes on the back of my neck all worsened and headache/brain fog increased to the point where even working from home was barely manageable. During this time, had extensive blood testing by a hematologist (Dr.) who followed me for resolution of blood clotting (which per testing was resolving during latter 2022). However, reduction of blood clotting did not relieve my other conditions at all. During this period, I additionally developed a severe inflammatory rash on my legs and upper arms that required treatment by a dermatologist with clobetasol (widespread red patching/blistering appearing like spattered burns). Additionally, the skin over most of my body had developed a significantly aged and crepe-paper appearance with brown spots appearing. Dr. noted the obvious wasting and discoloring of my legs, but subsequent scans showed no visible blood clotting in my legs. Muscle weakness/shakiness now clearly was observed to coincide with muscle loss throughout my body. Eventually, Dr. postulated I had likely developed an autoimmune condition from the vaccine, but that I was beyond his expertise at this point. Upon questioning Dr., he did not have any concern about my heart since I had normal EKGs and he recommended not resuming Androgel yet. All my conditions became extreme towards May 2022, and I had lost an estimated 10+ pounds of muscle mass. My heart would race/pound with the littlest exertion, like walking up a single flight of stairs in my home, sometimes accompanied by vague chest pain. I strongly petitioned my primary care, Dr. to help me secure a recommended rheumatologist, Dr., and a recommended cardiologist, Dr., both of which I saw right at the beginning of June 2022, along with an exercise stress ECHO through Dr. that showed enlargement of the right side of the heart. Dr. immediately recognized I had a significant ongoing autoimmune and inflammatory condition that required treatment as such  confirmed by several subsequent test results he ordered. He began treatment with prednisone packs and posited I never should have been taken off Androgel, which was also posited by Dr., and my urologist, Dr., since I had known hypogonadism and testosterone is key to cellular repair among other things. However, I did not resume Androgel until late in 2022 since Dr. had expressed caution about it. The inflammation/enlargement of the right side of my heart had likely been present for some time but was unrecognizable in multiple EKGs conducted in my primary care and Dr.'s offices. July through December 2022: Dr. and Dr. both took into consideration all my post-vaccine conditions, none of which existed in the slightest prior to the PfizerCV19 vaccinations, as an ongoing related constellation of vaccine-induced immune system reactions. Treatments were approached cautiously over time to include first daily 5 mg prednisone, then 200 mg hydroxychloroquine every other day progressing to every day by end of October and then resuming Androgel. By December I was prescribed an albuterol inhaler to ease breathing and enable beginning recovery exercise. The combination of these medications steadily began alleviating my conditions such that by this writing I have begun to lightly exercise again, focusing on muscle and stability recovery, but I still have some way to go*. The inflammation/enlargement of my right ventricle progressed downward to "mild" by mid December 2022 and hopefully will be resolved in ~6 more months. I also began strict 16-hr (8 PM to 12 noon next day) intermittent fasting in mid-November which has helped continue the gains.   In the years prior to the PfizerCV19 vaccinations I was quite healthy and active for my age with daily exercise every weekday, rewarding scientific career, youth groups, church leadership positions, etc. I had a green drink every morning along with, probiotics, low-dose enteric coated aspirin, vitamins, minerals, and omega3 soft gels. And from COVID-19 onward added extra vitamin C, D3, magnesium, potassium, and antioxidants as recommended by COVID prevention protocols. I added alpha-lipoic acid and milk thistle extract after the post-vaccination symptoms appeared. I had no congestive infection in 2019 or onward up until 25-Nov-2022, when I tested positive for COVID; minor head cold and tested negative on 30-Nov-2022. I had tested negative at numerous required times by both quick tests and PCR tests prior to the vaccinations and up to 25-Nov-2022, i.e., I verifiably never had COVID or any other congestive infection during COVID until 25-Nov-2022.  *Still must regain significant body wide strength, stability, energy, and endurance  lower legs are still as significantly affected or worse as experienced within days of receiving the 2nd PfizerCV19 vaccination, including neuropathy, requiring compression socks to feel more normal although general swelling has been down; still noticeable body-wide shakiness and low-level tremor; remaining "mild" heart inflammation/enlargement needs to resolve back to normal; still seems I cannot tolerate alcohol; skin conditions are unresolved from when they developed except the inflammatory rash that was resolved with topical clobetasol; using a regularly comparatively-calibrated oximeter from February 2022 to current, my oxygenation levels while sitting are consistently 92-94, and while active or right after are consistently 94-95. I still require an albuterol inhaler to breathe more freely during recovery exercise.  Primary Care  Dr.  Hematologist  Dr.  Gastroenterology  Dr.  Rheumatologist  Dr.  Cardiologist  Dr.  Urologist  Dr.