Received Mar 3, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| COVID19 | COVID19 (COVID19 (JANSSEN)) | JANSSEN | 1 | 1802068 | IM / RA |
| COVID19 | COVID19 (COVID19 (PFIZER-BIONTECH)) | PFIZER\BIONTECH | 2 | FD0809 | IM / LA |
A previously healthy 24-year-old female with no significant medical history received the Janssen COVID-19 vaccine on March 10, 2021. In October 2021, she contracted COVID-19, experiencing fatigue, congestion, and loss of smell, which has not returned. After recovering, she resumed physical activity, which triggered a relapse of symptoms with increased fatigue. She then received the Pfizer COVID-19 booster on January 22, 2022. Over the following months, she developed persistent fatigue, shortness of breath, chest pain, and post-exertional malaise. In mid-2022, she was diagnosed with POTS after participating in a Long COVID study. By early 2023, her condition worsened significantly, leading to chronic fatigue, muscle pain, and exercise intolerance, requiring extended leave from work. In December 2023, she left her job due to severe fatigue and mobility issues, later requiring a wheelchair. In July 2024, after a viral illness, her health rapidly declined, with significant weight loss, extreme fatigue, and severe hypersensitivity to light, noise, and touch. She was hospitalized, where workup showed an elevated D-Dimer but no other significant findings. Due to extreme fatigue and an inability to meet caloric needs, a feeding tube was placed. By September 2024, she lost the ability to move on her own and became fully bedbound, requiring 24/7 care. She was readmitted in December 2024, but extensive testing (MRI, CT scan, chest X-ray, ECHO, and labs) was inconclusive aside from continued elevation of D-Dimer. No further treatment was offered. Before discharge, a spike protein test was drawn and later found to be extremely elevated. Since February 12, 2025, she has been on a spike protein detox protocol, but her condition remains severe, with no significant improvement yet. She continues to experience extreme sensitivities to light, noise, and touch, remains fully bedbound, and requires 24/7 care. Despite her critical condition, insurance has denied nursing care, categorizing her case as "respite" rather than medical necessity. This has placed a severe burden on her father, who is her primary caregiver while also trying to maintain his job. The family has struggled to secure adequate care, resorting to hiring a nurse, but consistent, professional medical support remains a major challenge. She will need intensive rehabilitation, including physical and occupational therapy, to regain mobility. Given the timeline of symptoms and deterioration following vaccination and booster administration, this case represents a severe post-vaccine injury with possible long COVID overlap.
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None prior to the Covid vaccine
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08/16/2024 D-dimer 1.64. 12/2024- elevated spike protein, >2500