Age: 59.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Hepatic enzyme increased, Hyperventilation, Influenza like illness, Insomnia, Joint swelling
Clinical narrative: In a nutshell, patient was fine, got the first shot of the Moderna Vaccine on 3/24/21, then began to exhibit many covid-like symptoms starting around 4 hours later but 3 times nasal swap tested negative for COVID19 including before and after vaccination. Suffered with various attempts at treatments and tests for approximately a month and then was admitted to the ER at hospital on 4/28/21.  Wife (former smoker who lives in same house and has lung problems) who took the vaccine at the same time from the same lot suffered minor arm pain, aches and pains and fatigue but was fine the next day.  Patient (59) had normal blood pressure and clear lungs in good health, non-smoker, good weight, exercises regularly and strenuously, good diet, rarely gets ill. He works as a ship?s captain and engineer and has worked in boatyards for years doing physical work. Has tintinnitis and in one eye, glaucoma drops but is on no other prescription medicines. Details: March: had nasal congestion, cough and suspected bronchitis, aches and pains, no fever, PCR tested negative for COVID19, and was treated with antibiotics (azithromycin and then a run of amoxycillin), proair, advair discuss a couple of days, various vitamins/minerals, over the counter cold/flu medicines. Seemed to work with most symptoms going away prior to Marcch 24, 2021. March 24, 2021 morning: Got first shot of the Moderna Vaccine at pharmacy. Lot 045A21A at same time as spouse. That morning had no cough and felt ok. Approximately 4 hours later, patient started to cough, felt congested, felt like flu/pneumonia, trouble breathing, aches and pains especially in joints, extreme fatigue, headache, (but suffered no loss of taste or smell throughout 3/24-present) took Theraflu and went to bed early, slept well. Following days, struggled with intensifying symptoms. Felt like the vaccine gave him covid symptoms without the loss of smell/taste.  Spouse experienced minor pain at point of injection, some fatigue, aches and pains which went away by end of next day 3/25/21. Spouse had some lingering cough left over from earlier bronchitis before getting the vaccine which cough/congested breathing continued with no noticeable change. [Spouse was also not adversely impacted by the second shot of Moderna vaccine a month later.) Apr Wk1 & Wk2: Increasing difficulty sleeping due to lung congestion or suddenly waking up wide awake for no reason. At end of Wk2, had some minor tremors in muscles for a couple of days. Suffered from extreme fatigue, congestion, trouble breathing, nightmares, aches and pains. Took azithromycin run then a run of amoxicillin, proair, prednisone, albuterol nebulizer, occasional Theraflu or over-the-counter cold/flu medicines, vitamins/minerals (including heavier doses of Vitamin D, Zinc, C, etc.), probiotic acidophilus, tonic water with quinine or Perrier, melatonin 10mg and magnesium 500mg at night, occasionally a Unisom sleeping pill. Started to lose appetite where rarely hungry. Would force himself to eat anyway, but occasionally vomited it up. Apr Wk3 4/13/21: Patient got another PCR covid test which was negative, chest xray, blood work done at Urgent Care. Showed some elevated liver/kidney enzymes and low red blood cell count/anemia, vague thickening of the plura, swollen lymphnode in the chest xray, no sign of cardiovascular issue. (Some yellow flags but nothing flashing red.) Dr. recommended followup tests and bloodwork and that he get GI/Cardio/pulmonary workups w/specialists. Patient continued to take antibiotics, pregnizone, albuterol nebulizer, vitamins/minerals, and occasional cold/flu/cough medicines, etc. Added SuperB Complex. One day he had hot/cold chills for a few hours. Apr Wk4: While lungs felt clearer, still coughing and now occasionally vomiting productively or dry heaves, insomnia grew into bigger issue with hallucinations not just with nightmares but occasionally during the day where it was difficult to separate reality from dream, trouble remembering, started to feel paranoid/irrational sometimes, trouble sleeping was not due to lung congestion but more due to panic-attack like heavy breathing or sudden central chest/sternum pain (maybe from coughs), aches in joints, but biggest problem was extreme fatigue and tiring when walking up a flight of stairs, etc. Took some Tramadol occasionally for pain relief (but never with aspirin, Tylenol or cold medicine). Could be sitting comfortably watching a mellow tv program but suddenly need to breathe really heavy, hyperventilating and felt need to standup and walk around until it eased. Extreme trouble sleeping. Most comfortable position was kneeling with body bent over a pillow on the bed. [He'd never had panic-attacks/heavy breathing issues before the Moderna shot and doesn't abuse substances.] Wk5: 4/24/21 feet swelled up and turned purple on the soles. Went for a walk around the block and raised feet. No longer on antibiotics or pregnizone, only taking the albuterol nebulizer, vitamins/minerals/probiotics, melatonin and a OTC cough/flu medicine before bed. Knelt for hours while trying to sleep. 4/25/21, feet more swollen with fluid and more discolored. When searched online, they looked like "covid toes". Took no medicines except nebulizer and took only a couple of vitamins/calcium-vitaminD and before bed a beer, melatonin, magnesium & nyquil. 4/26/21, feet less swollen and no longer purple except a small line on the side of one foot. Patient indicated he had not knelt when trying to sleep prone during night. But only got a couple of hours of sleep, nighttime hallucinations and panic-breathing attacks. Daytime inability to focus, extreme fatigue, aches and pains, quick to tire on any exertion, vomiting food or dry heaves 2 or 3 times that day, panic-like-attacks with need to heavy breathe/hyperventilate. Wheezing with occasional rattle at end. Coughs sometimes productive, sometimes not but lungs didn?t feel very congested and oxygenation/blood pressure was good. 4/27/21, went to work in morning and was able to perform but very tired. In early afternoon, came home, ate, took nyquil and nebulizer and tried to sleep. 4/28/21, felt much worse, feet and knees swollen, extreme exhaustion, felt miserable. Went to work anyway. Came home around 2pm, ate. Felt much worse so we went to the ER at Hospital. Spouse provided MMC with his medical conditions, medicines, the info on COVID IGG serology test and informed them of the chest xrays and bloodwork that had been done at the Urgent Care center 2 weeks prior. ER indicated he needed to stay overnight and they performed additional bloodwork, xrays, scans and MRIs. The ER doctor called in specialists in Nephrology and Cardiology to provide consultations.