Age: 68.0
Sex: M
Vaccine: COVID19
Symptoms: Magnetic resonance imaging, Muscular weakness, Myelitis transverse, Pain, Pain in extremity
Clinical narrative: diagnoses with transverse myelitis; temperature changes; Muscle weakness; gait is fumbled, balance issues; gait is fumbled, balance issues; pain in left arm after doses; skin on thighs hurts to the touch; near his ribs is tingling and prickling; near his ribs is tingling and prickling; This is a spontaneous report received from contactable reporter(s) (Consumer or other non HCP).  A 69-year-old male patient received BNT162b2 (BNT162B2), on 05Mar2021 as dose 2, single (Lot number: EN6202) at the age of 68 years, in left arm for covid-19 immunisation. The patient's relevant medical history included: "Blood pressure" (unspecified if ongoing). Concomitant medication(s) included: LISINOPRIL oral taken for blood pressure abnormal. Vaccination history included: BNT162b2 (LOT- EN5318 or RN5318- Hard To Read On Vaccine Card, Anatomical Location: Left Arm), administration date: 29Jan2021, when the patient was 68-year-old, for COVID-19 immunization.  The following information was reported: MYELITIS TRANSVERSE (medically significant), outcome "not recovered", described as "diagnoses with transverse myelitis"; BODY TEMPERATURE ABNORMAL (non-serious), outcome "not recovered", described as "temperature changes"; MUSCULAR WEAKNESS (non-serious), outcome "not recovered", described as "Muscle weakness"; GAIT DISTURBANCE (non-serious), BALANCE DISORDER (non-serious), outcome "not recovered" and all described as "gait is fumbled, balance issues"; PAIN IN EXTREMITY (non-serious), outcome "unknown", described as "pain in left arm after doses"; SKIN SENSITISATION (non-serious), outcome "not recovered", described as "skin on thighs hurts to the touch"; PARAESTHESIA (non-serious), PAIN (non-serious), outcome "not recovered" and all described as "near his ribs is tingling and prickling". The events "diagnoses with transverse myelitis", "temperature changes", "muscle weakness", "gait is fumbled, balance issues", "pain in left arm after doses" and "near his ribs is tingling and prickling" required physician office visit. The patient underwent the following laboratory tests and procedures: Blood pressure measurement: (unspecified date) Unknown results; Body temperature: (unspecified date) temperature changes in his body; Magnetic resonance imaging: (04Apr2022) that there are two areas in the spinal cord that, notes: show the myelin is missing causing misfires.diagnosed with transverse myelitis in Apr2022. /which showed the missing myelin sheath in the spinal cord. Therapeutic measures were taken as a result of myelitis transverse, body temperature abnormal, muscular weakness, gait disturbance, balance disorder, pain in extremity, skin sensitisation, paraesthesia, pain.  Clinical Course: Caller was calling on behalf of her husband. States her husband had the Pfizer Covid vaccine, had two doses, and within 6 weeks after he started having these temperature changes in his body and muscle weakness and he has been through 3-4 doctors and diagnosis is that the virus has attacked the myelin sheath causing all of these issues with his weakness, temperature, and lower extremity weakness, his thighs- it hurts to touch his skin, by his ribs on one side is tingling and prickling all the time. Caller states the patient's MRI showed that there are two areas in the spinal cord that show the myelin is missing causing misfires. diagnosed with transverse myelitis in Apr2022. Began within 6 weeks of the second dose of the Pfizer Covid vaccine. Exact dates are unknown. Caller states the patient reports his symptoms are worsening, that he is losing muscle mass and strength. Neurologist did a scan on 04Apr2022, which showed the missing myelin sheath in the spinal cord. TREATMENT: Neurologist put him on IV steroids for a week straight in Apr2022, exact dates unknown. Caller states this did not work. Product information Unknown for Steroids. Exact name of product unknown. Also, patient was given 900mg of Gabapentin to help him sleep, states he was on this for 2 months and it didn't work either- 300mg by mouth for two days, then one by mouth twice for 2 days and then by mouth TID(three times a day). History of all previous immunization with the Pfizer vaccine considered as suspect.Caller states that the patient received Steroids and Gabapentin for treatment of the filed event. States neither of these medications worked for the patient. Caller does not have any specific details of either the steroid treatment or the Gabapentin to provide