Age: 68.0
Sex: F
Vaccine: COVID19
Symptoms: Fatigue, Headache, Investigation, Vaccination site pain
Clinical narrative: Severe Headache; Fatigue; Slight pain at injection site on left arm; This is a spontaneous report received from a contactable reporter(s) (Other HCP). The reporter is the patient.  A 68 year-old female patient received bnt162b2 (BNT162B2), intramuscular, administered in arm left, administration date 17Feb2021 (Lot number: EN6200) at the age of 68 years as dose 1, single for covid-19 immunisation. Relevant medical history included: "Systemic lupus erythematosis", start date: Feb1992 (unspecified if ongoing); "Sjogren's disease", start date: Jan2020 (unspecified if ongoing); "Inflammatory Bowel Disease", start date: Feb1997 (unspecified if ongoing); "Ulcerative Colitis", start date: Feb1997 (unspecified if ongoing); "Asthma" (unspecified if ongoing); "bronchiectasis" (unspecified if ongoing); "autoimmune diseases" (unspecified if ongoing); "Liver Cirrhosis" (unspecified if ongoing), notes: It is genetic because she has Alpha 1 Antitrypsin deficiency. It is ZZ pheno type which causes Liver Cirrhosis and lung disease, COPD and emphysema.; "lung disease" (unspecified if ongoing), notes: It is genetic because she has Alpha 1 Antitrypsin deficiency. It is ZZ pheno type which causes Liver Cirrhosis and lung disease, COPD and emphysema; "COPD" (unspecified if ongoing), notes: It is genetic because she has Alpha 1 Antitrypsin deficiency. It is ZZ pheno type which causes Liver Cirrhosis and lung disease, COPD and emphysema.; "emphysema" (unspecified if ongoing), notes: It is genetic because she has Alpha 1 Antitrypsin deficiency. It is ZZ pheno type which causes Liver Cirrhosis and lung disease, COPD and emphysema. Concomitant medication(s) included: SEREVENT, start date: 02Mar2021.  The following information was reported: HEADACHE (non-serious) with onset 27Feb2021, outcome "recovering", described as "Severe Headache"; FATIGUE (non-serious) with onset 17Feb2021, outcome "recovering", described as "Fatigue"; VACCINATION SITE PAIN (non-serious) with onset 17Feb2021, outcome "recovering", described as "Slight pain at injection site on left arm". Relevant laboratory tests and procedures are available in the appropriate section.  Clinical course: Received call from patient regarding Pfizer COVID 19 vaccine. She took second dose yesterday and is experiencing normal side effects such as a 101.3 degree fever, chills, severe headache, body aches with muscles in legs and arms, back pain, fatigue, and lymph nodes on both sides of neck are slightly enlarged. With the first dose, she only had a headache, fatigue and slight pain at injection site. The fatigue was for 4 days and headache was moderate. The date she had the first dose was 17Feb2021. She had an additional symptom today that she wanted to ask about. Her lungs hurt especially if she breathed in and out. Could it relate to the muscles around that She signed up for Vsafe, so they know the first day symptoms, but they have not contacted her. She does have COPD, and she does not smoke. It is genetic because she has Alpha 1 Antitrypsin deficiency. It is ZZ pheno type which causes Liver Cirrhosis and lung disease, COPD and emphysema, and she does not smoke or drink alcohol. She also has bronchiectasis. She has autoimmune diseases. She stated she does not feel very well. She has been in quarantine since Mar2020. There was no prescriber for the vaccine. Her lungs starting hurting around 12:30 today. The other symptoms were last night around 11:30. The second dose was given 08Mar2021, and lot number is EN6205, with no expiration. It was also given intramuscularly in the left arm and was also a Pfizer product. She wanted to get the Pfizer one. She just started on an inhaler twice daily for shortness of breath. She has some other things and does not think they are concerning. No further details provided. She is seeing an immunologist for asthma and they are looking at T cells and B cells. The T cells she has a low value. This occurred before she got the vaccine in Feb2020. She could not find any literature on the lung muscles being sore in any of the literature, so she wanted to find out about if that could be related.   No follow-up attempts are possible. No further information is expected.