Initial Consultation Note Of A Patient With Severe Covid Vaccine Injury Syndrome

One of my sicker and most difficult to treat patients, his condition one year under my care is only marginally improved despite over a dozen trials of therapies.

11/01/2022 4:48 pm - I saw “Alan” in the evaluation of post vaccine injury syndrome today. He is a 23-year-old African American man who prior to becoming injured was in college studying English as his major, and in addition he was an active musician, artist, and writer. His only significant medical history was asthma since childhood along with allergies and he was managed on Flovent, Singulair, as well as occasional Benadryl and Zyrtec when his allergies acted up along with a rescue inhaler of albuterol. He has only been admitted once to the hospital for asthma at the age of 12. He lives in an apartment with his mother and brother.

He reports that in June of 2021 he received his Covid vaccine at Rite Aid in the morning. 2 hours later he noticed that his left arm where he received the injection was starting to tremor. He went home, took some Motrin and took a nap. However this recurred the next day except now it involved both arms and it got worse over the next 5 days. He visited the emergency room, they ruled him out for rhabdomyolysis and told him to hydrate himself - he reports that that episode of tremors lasted 12 hours.

Soon after that the tremors started to involve his lower extremities. He had multiple episodes a day, he saw his primary care provider who did a CT of the head which was negative then referred him to neurology and at that point he reported all 4 extremities with tremors. Although the neurologist discussed with him the likelihood that this was related to the vaccine his official documented diagnosis was functional neurological disorder. Alan’s mother called Moderna in order to try to get some help or insight into what was happening however they were of no help. At his second emergency room visit they did another CT scan and labs and then they they said “they could not make the diagnosis in the emergency room.”

Later that July of 2021 he saw a movement disorder specialist who again diagnosed Alan with functional neurologic disorder. They referred him to physical therapy however each session triggered and worsened his symptoms. He then started to develop dystonic reactions which were triggered by heat, cold, or massage. This facial dystonia caused him to be unable open his eyes or his jaw would became clenched such that he couldn’t eat, drink, or talk or his head would turn in a fixed position akin to torticollis. He also started developing chest paralysis/inhibitions as well as arching of the back.

He saw a second neurologist in July of 2021, a movement disorder specialist who did another MRI, which was reported as an ill-defined abnormal signal over the left parietal area of unknown significance. He then started developing ballismus as well as flaccid episodes, and at one point he was put in the hospital for 3 days where he was given pulse dose intravenous Solu-Medrol (a corticosteroid), a gram a day for 3 days after which he reported significant improvement given he suddenly had no symptoms for the next 2-4 days but then the symptoms slowly recurred however his brother says that they were not as severe as they were prior. They went back to the emergency room, neurology saw him again but refused to offer him any more treatment. He also went to the NIH where he was being evaluated for a study of functional neurologic disorder and then was referred to a neuro-immunologist who did not see him due to some stated conflict of interest? He then was referred to Columbia where he again received the diagnosis of functional neurologic disorder.

At one point he was given Klonopin on which he remains where he takes a half a milligram in the morning and then 0.25 mg in the middle of the day and at the end of the day. However he and his family say they are using these low doses so that they do not run out given it is the only thing that mitigates the severity of his symptoms throughout the day. Given the frequency of these alternating episodes of flaccidity, dystonia, and ballismus he cannot be left alone at home and is under total care and supervision by his devoted mother and brother.

Overall in terms of his worst symptoms he reports that the flaccid episodes are the worst where his extremity and trunk loses all strength and movement and this can last for minutes to hours and happens multiple times a day. Sometimes his limbs turn cold and pale during these episodes. The second most pressing symptom is ballismus episodes akin to Huntington’s disease where his arms and legs kick and punch and he has actually damaged walls around the apartment. His brother tackles him to the ground and lies on top of him during these episodes to prevent Alan from hurting himself or the furniture or walls, in which there are numerous holes. Third is dystonic episodes where his jaws are clenched or locked and he has difficulty speaking and eating or drinking, this also happens daily and then lastly he gets fasciculations as well as tremors however this does not happen every day. The least common is where he has vocalization episodes where he whistles and/or shouts uncontrollably and in addition he reports episodes of eye rolling.

IMPRESSION: Severe post vaccination injury syndrome consisting largely of systemic neurologic motor dysfunction as stated above. I suspect sub-radiographic diffuse brain and/or brainstem inflammation.

I reviewed the numerous possible pathologic mechanisms likely contributing to his symptoms: inflammation/macrophage/monocyte activation, autoimmunity to tissues, "micro-clotting" (platelet activation and aggregation, amyloid fibrils, fibrin, RBC aggregation), mast cell activation syndrome, nitric oxide pathway dysfunction, mitochondrial failure).

PLAN: I propose the following initial sequence of trials of therapy:

Given that he has responded to steroids and Klonopin I believe we should re-start corticosteroids and increase dosing of the Klonopin first, and then begin him on a regimen of medicines with mechanisms that counteract the currently known pathologic processes induced by the vaccine. I propose we do the following:

1) Start prednisone, 80 mg daily for 2 weeks, establish a new clinical baseline after which we will begin ivermectin 0.3mg/kg (36mg) daily as well as low dose naltrexone as follows: 10mg/cc in a 20cc bottle (1 drop = 0.5mg). Start with 2 drops under the tongue at night and increase by one drop every 5 nights until you notice more refreshed sleep. Can go up to 8 drops daily. Half the dose if nausea or insomnia develop or worsen. In regards to high dose corticostoid use at home, please purchase a glucometer so we can monitor blood glucose levels. *(I later doubled the dose and he required insulin for a short time).

2) Once Alan starts on the ivermectin and low dose naltrexone, decrease prednisone to 60mg daily for a week, 40mg daily for a week, 20 mg daily for a week, then 10mg daily for a week. Once on 10mg daily, we will taper off as follows:

- take 10mg alternating with 5 mg every other day for 6 days, then 5mg for 6 days then 5mg alternating with nothing for 6 days

2) Increase klonopin to 0.5mg three times daily as needed for control of symptoms. There is a concern for dependance here however, the hope is that with better control of symptoms with the above, we can begin to taper off klonopin dosing as tolerated and further, not using this medication will lead to an immense increase in the suffering described by Alan.

Please check in with me via the portal in two weeks to assess the efficacy and re-confirm the soundness of the above approach. My nurses will follow up with you this week. I also think within a month we should start considering initiation of HBOT

*Note this consultation was from a year ago and my practice has evolved considerably. I now employ numerous other therapeutic trials which I use in different sequences, with these sequences varying from patient to patient.

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