Age: 65.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Arthralgia, Loss of personal independence in daily activities, Mobility decreased, Muscular weakness, Pain
Clinical narrative: she has lost eyelashes on the right handed side as well; shoulder pain or denervation/she is asleep the pain wakes her up; She lost the range of motion in her arm and has had difficulty doing simple ADL's. The pain is pretty continual; chronic degeneration in most muscles in the right upper extremities to be radiating down into her wrist and moderate right carpal tunnel syndrome; chronic degeneration in most muscles in the right upper extremities to be radiating down into her wrist and moderate right carpal tunnel syndrome; Most of the pain is in her upper arm and shoulder and right side of her neck. It is all in the right side of her body.; Most of the pain is in her upper arm and shoulder and right side of her neck. It is all in the right side of her body.; losing the range of motion to pain, most of the time, handwriting and everything seems to be affected.; difficulty writing; The loss of range and motion/lost ability to raise up her arm; The loss of range and motion and pain in her arm are worse, not better.; pretty significant muscle pain in the right arm; Tremors on the right side/In the right arm, in the hand. Noticed when holding out hand and shaking hands; This is a spontaneous report from a contactable consumer (patient). A 66 years old female patient received BNT162b2 (PFIZER BIONTECH COVID-19 mRNA VACCINE, Solution for injection, Batch/Lot Number: EN6202, Expiration date and NDC number was unknown), via an unspecified route of administration, administered in right arm on 26Feb2021 probably around 16:45 hours as dose 2, single (at the age of 65-years-old) for COVID-19 immunisation. Medical history included ongoing Type II diabetic, had a tumor in her pancreas and thought it was malignant (It was not, thank goodness. They thought it was going to be so, they removed her spleen and gall bladder) from 2007 to an unknown date, ongoing HLA B 27 auto immune disorder (genetic), spleen removal from an unknown date and unknown if ongoing, gallbladder removal from an unknown date and unknown if ongoing, ongoing ADD (Attention deficit hyperactivity disorder, has been taking a long time, years), ongoing compromised immune system and ongoing sleep disorder (taking Alprazolam for sleep) and patient never had pain when sleeping, she just kind of had insomnia. She could get to sleep but would just have trouble staying asleep. Historical vaccine included patient received BNT162b2 (PFIZER BIONTECH COVID-19 mRNA VACCINE, Solution for injection, Batch/Lot Number: EL9269, Expiration date and NDC number was unknown), via an unspecified route of administration, administered in right arm on 05Feb2021 around 16:00 hours or 16:35 hours as dose 1, single (at the age of 65-years-old) for COVID-19 immunisation. Patient had no additional vaccines administered on same date of the Pfizer suspect. Patient had no prior vaccinations (within 4 weeks). Concomitant medication(s) included temazepam (Temazepam Actavis) taken for sleep from an unspecified start date and ongoing; alprazolam taken for sleep (when really hard getting to sleep) from an unspecified start date and ongoing; empagliflozin, metformin hydrochloride (Synjardy) taken for diabetes, start and stop date were not reported; sitagliptin phosphate (Januvia) taken for diabetes from an unspecified start date and ongoing; colecalciferol (Vitamine D) taken for supplement from an unspecified start date and ongoing; omega-3-acid ethyl ester (Lovaza) taken for vitamin E from an unspecified start date and ongoing; lisdexamfetamine mesilate (Vyvanse) taken for ADD from an unspecified start date and ongoing; ascorbic acid (Vitamine C) taken for an unspecified indication from an unspecified start date and ongoing. On an unspecified date of 2021 (since her second dose of the vaccine), patient experienced significant muscle pain in the right arm, were she received the vaccine. Patient had a worsening condition since receiving the second dose of the vaccine. It began in the arm she was injected in, with pretty significant muscle pain in that arm. Patient kind of shrugged it off the first couple of weeks, thinking they were warned that it could cause some arm pain. She just thought it was typical.  It proceeded to get worse. On unspecified date of 2021, patient lost the range of motion in her arm and has had difficulty doing simple ADL's. Patient out of desperation she checked the VAERS website and she saw quite a few reports like hers where several surgeons reported loss of range of motion and difficulty with activities of daily living (ADL). The pain was pretty continual. It wakes her up at night and, if she happens to roll on her arm, it wakes her up several times in the night with pain. Patient stated that it was pretty bad, since Feb2021, it had been getting progressively worse, right now, she does not know if she could had even prevented it. Patient was a little concerned, if it was possible to make things worse from getting a booster. No specialist that she had been dealing with had been able to give any advice. Both the neurologist and the orthopedic surgeon don't know enough about the Pfizer vaccine to answer questions on if they think she should get the booster. Patient had her sore arm and losing the range of motion to pain, most of the time, handwriting and everything seems to be affected. She was right handed and had difficulty writing and difficulty doing a lot of things she used to be able to do. It was very frustrating raising 2 grandchildren. It had affected her job. Patient would still get the vaccine. It had definitely been proven that it does prevents hospitalization and deaths. Patient ended up at her primary care doctor and rheumatologist could have gotten help a lot quickly if even a possibility. She had nothing with the first vaccine. The second Pfizer vaccine, her arm was much more sore. It was painful from the get-go, from the injection. She thought that was normal. She heard that a lot of people had complained about injection site pain. Within 2 weeks, the pain never went away from the shoulder. Odd things started happening. She lost her ability to raise her arm up and noticed when reaching in the cupboard for dishes, and glasses and reaching for clothes, and trying to get dressed, it was very painful to put clothes on. Like putting a bra on, she couldn't even reach around her back or reach up for anything to save her life. She started getting more concerned. It was also during the time period where it was really hard to get in to see a physician because of Covid. Physician were still in the process of trying to get really accurate treatment. They prescribed physical therapy and are thinking of discontinuing it because they are not seeing any improvement. She was pretty worried. The loss of range and motion and pain in her arm are worse, not better. The pain seems to be getting worse. It was radiating down her arm, into her back and was getting progressively worse. That was why she was concerned. On an unspecified date of 2021, (probably May2021 or Jun2021), patient in the right arm, in the hand had tremors. Noticed when holding out hand and shaking hands. It was tremors, looks like tremors. At first, she noticed because her handwriting and all these things were getting progressively worse. It all happened from the time she had the second injection. It seemed like she kept developing new, odd symptoms. She first noticed the handwriting and her greatly impaired signature. It looks very different than it did before she had the second vaccine. When she noticed the handwriting, she knew something was going on. She started noticing her hand shaking and was now beginning to drop things. If she was holding a glass in her hand, it will sometimes just drop out of her hand. That had never happened before. Whatever was going on was actually not getting better, was getting worse. Everybody stated that they don't know about the constant pain and everything they were hearing from the doctors. They don't know what to expect with this vaccine. A couple of these have been seen in other patients but hers were more severe. Treatment: The first doctor she saw, the rheumatologist said she does not have a spleen and has a compromised immune system. She prescribed Meloxicam. It did not do anything, did nothing for the pain. The Gabapentin did not do anything either, it made her sleepy but did not take the pain away. She went to her primary care physician and thought she needed a Medrol dose pack. He referred her to the orthopedic specialist and neurologist. The original neurologist did not prescribe anything that helped. The neurologist prescribed horrible medication. She could not function on it. It made her want to sleep all day and all night. The product was Gabapentin was 100mg, three times a day. 90 pills came in the bottle. It was once a day. It through her for a loop when she took the 3. She did not feel human being on that drug. She had to stop it. There was no way she could stay on that and be able to function or do anything. Then, they put her on another medication, she thinks Cymbalta. It made her too sleepy during the day and just really sleepy. She stopped taking that. That was when the EMG was ordered. Eventually, this summer, in Jul2021, she was able to get in to see a neurologist and an orthopedic specialist. On 15Jul2021, EMG (electromyogram) was done, patient had chronic degeneration in most muscles in the right upper extremities to be radiating down into her wrist and moderate right carpal tunnel syndrome. Most of the pain was in her upper arm and shoulder and right side of her neck. It was all in the right side of her body. EMG results were abnormal study with evidence of chronic degeneration in the most of the muscle of the right upper extremity. A distal median motor and sensory neuropathy possibly from a moderate right carpal tunnel syndrome. Non specific ulnar neuropathy possibly associated with diffuse process in the arm. EMG finding may be an indication of chronic brachial plexopathy polyradiculopathy or motor neuron diseases were less likely. Patient sees her doctor every 6 months or frequently, if we ever need to get ahold of her blood tests. Nothing abnormal had shown up that they were aware of. The MRI for brachial plexus polyradiculopathy, they were supposed to do this week, it was waiting to be scheduled. On Jul2021, the other odd thing, she does not know if it was related or not, her eye lashes on the right side were falling out to where they were very, very noticeable on Jul2021. Eye lashes falling out in clumps. It was not just one or two. At least a quarter of an inch in a section of her right eye lash. It looks horrible and was embarrassing. She had seen a dermatologist once for it. She wants to do a biopsy. She did not know what was causing it either. She was scheduled for that 30Aug2021. She told her to not wear false eye lashes. They look very odd. It was very disturbing. It had not happened on the other side. It was so strange. It started in Jul2021. She may had noticed it around 1Jul2021 when she became concerned. At first, she thought it was typical shedding. It just continued and was very visible and odd looking. It has gotten worse. It first started happening at the ends of the eye lashes. It now was happening in a big space in the middle. It was horrible. Everybody was looking directly at her. Would notice it and can't hide, even with a mask. Patient saw her primary care physician who referred her to the neurologist and orthopedic specialist. When coming off the 2 other medications, he saw the orthopedic specialist. He tried the Methylprednisolone, which was the Medrol dose pack provided no relied for the pain. It did not do what was supposed to do. They wondered what they were supposed to do next. That was when they ordered the MRI. The orthopedic specialist also ordered physical therapy 2 times a week, for a month. She just finished a session yesterday. It does not seem to be helping her range of motion.  They were not seeing any improvement. Insurance was not going to allow it to continue if they were not seeing any improvement. It was very frustrating. The neurologist did the actual EMG study and said he was going to report it to VAERS. She was going to see him 1Oct2021. Patient had been to some specialist such as a neurologist and orthopedic specialist and they don't seem to know what was causing this reaction. Patient stated that she was concerned about the booster shot because of the pain and she would like to know if she should get it in the same arm or opposite arm and also like to know if the booster dose will make things worse. Patient stated that her neurologist told her that her side effects may be associated with the Pfizer COVID vaccine and he said that he was going to report if to the VAERS system so that was why she was concerned even though he said that. Patient stated that the orthopedic specialist said they don't know what was in the vaccine and that her case was more severe than he had seen. Patient stated that the neurologist and orthopedic specialist could not advise her on whether or not she should receive the booster and what arm she should get it in. Patient stated that her rheumatologist told her she thinks she needs to get it. Patient stated she had been advised to get the booster since she was immunocompromised due to not having a spleen or HBN07. Patient stated that she was also raising her grandchildren and she lives in Texas and they were not mandating masks at school, but her granddaughter wears one and she doesn't want to get sick and wants the booster, but she just does not know if she should or what to do. Patient would like to know if we have any information regarding Brachial plexopathy or continuing shoulder pain or denervation after any of the Pfizer COVID vaccines.  Patient stated that her side effects was very painful and doing the most simple tasks such as putting on a bra, putting on pants, or even reaching for a glass this was so painful and at night when she was asleep the pain wakes her up. Patent stated that she was looking for some relief or prognosis and would like to know if there was any information regarding these conditions. Patient would like to know if she should switch to Moderna COVID vaccine for the booster after receiving the Pfizer COVID vaccine and experiencing side effects and stated that her doctor told her that she should stick with Pfizer but she was not sure due to the side effects. Patient had no emergency room visit. Patient had physician office visit for the events. The outcome of Most of the pain is in her upper arm and shoulder and right side of her neck. It is all in the right side of her body and carpal tunnel syndrome was unknown and not recovered for rest of the events.