Received Oct 23, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| COVID19 | COVID19 (COVID19 (MODERNA)) | MODERNA | 1 | 031A21A | IM / RA |
| COVID19 | COVID19 (COVID19 (MODERNA)) | MODERNA | 2 | 044B21A | IM / RA |
Vaccine: Moderna COVID-19 mRNA-1273 (lots 031A21A and 044B21A, given March and April 2021). Immediately after each vaccination the patient experienced intense fatigue, body aches, and malaise, remaining in bed and largely unable to move for approximately 24?36 hours after each dose. No hospitalization at that time; symptoms resolved over two days. He remained well until November 2022 when he contracted COVID-19. About one month later, on 12/17/2022, he presented to ER with severe abdominal pain and diarrhea. CT abdomen/pelvis showed acute colitis extending from the cecum to mid-transverse colon with possible terminal ileitis. He was treated with Augmentin and prednisone and referred to gastroenterology. On 02/07/2023 colonoscopy by revealed visually normal mucosa; biopsies were taken. On 02/17/2023 he returned to the ER for headache and sore throat; strep testing was positive and CT head was performed (no acute intracranial findings). By mid-2023 he developed progressive visual changes and was diagnosed with Coats disease (retinal vascular injury described as an ?eye stroke?). He experienced two additional COVID-19 reinfections after the November 2022 episode (between 2023 and 2025), each followed by temporary fatigue and worsening of inflammatory symptoms. Through 2024 he underwent testing showing microclot formation and began a spike-clearance protocol including Neprinol (fibrinolytic enzyme), low-dose naltrexone, N-acetyl-L-cysteine, melatonin, vitamin D, and other mitochondrial-support supplements. Spike-antibody titers have remained at or above the laboratory upper limit (>10 000 U/mL) on multiple occasions between 2021 and 2025 despite no additional vaccination. These persistently elevated levels were noted by clinicians during evaluation for inflammatory and microclotting symptoms. Overall course: early post-vaccination systemic reactions with prolonged bed rest, followed nearly 20 months later by gastrointestinal inflammation, recurrent infections, retinal vascular disease, and subsequent reinfections associated with ongoing fatigue and inflammation. The patient continues follow-up with gastroenterology, hematology, and integrative-medicine providers for ongoing vascular and inflammatory evaluation. Current status: improved but not fully resolved.
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CT abdomen/pelvis 12/17/2022 ? showed acute colitis extending from the cecum to mid-transverse colon with possible terminal ileitis. CBC and CMP same date ? hemoglobin 18.6 g/dL, hematocrit 56%, platelets 116k, normal electrolytes. Colonoscopy 02/07/2023 ? visually normal mucosa, biopsies taken (no inflammatory bowel disease reported). CT head 02/17/2023 ? performed for headache, no acute intracranial findings. LabCorp comprehensive panel 06/23/2023 ? LDL-C 174 mg/dL, non-HDL 198 mg/dL, A1c 5.5%, vitamin D 57 ng/mL, eGFR 111 mL/min/1.73m². Ophthalmology mid-2023 ? diagnosed Coats disease/retinal vascular injury (?eye stroke?) with visual field changes. Microclot testing 05/23/2024 ? documented abnormal clotting patterns consistent with microclot formation. Spike antibody titers repeatedly >10,000 U/mL on testing from 2021 through 2025 with no decline over time despite absence of additional vaccination.