Age: 70.0
Sex: M
Vaccine: COVID19
Symptoms: COVID-19, Chest X-ray, SARS-CoV-2 test, Vaccination failure
Clinical narrative: COVID-19 after being fully vaccinated and had boosters twice; COVID-19 after being fully vaccinated and had boosters twice; This is a spontaneous report received from contactable reporter(s) (Consumer or other non HCP). The reporter is the patient.  A 70-year-old male patient received BNT162b2 (BNT162B2), on 21Jan2021 as dose 1, single (Batch/Lot number: unknown) at the age of 69 years, on 11Feb2021 as dose 2, single (Batch/Lot number: unknown) at the age of 69 years, on 08Sep2021 as dose 3 (booster), single (Lot number: FC3181) at the age of 70 years and on 15Mar2022 as dose 4 (booster), single (Lot number: FK9894) at the age of 70 years for covid-19 immunisation. The patient's relevant medical history included: "Prediabetes" (unspecified if ongoing), notes: Comments: Prediabetes. The patient's concomitant medications were not reported. Past drug history included: Metformin, start date: 2021, stop date: 2022, for Prediabetes, reaction(s): "digestive issues", notes: Caller says he had some digestive issues that he thinks was related to a medication, which he doesn't have diabetes but is considered prediabetic, so he was taking Metformin, and after he stopped taking it his stomach troubles went away. He took Metformin HCl ER 500mg and was taking two tablets twice a day and was taking it for almost a year, starting in 2021 because he doesn't think he was taking it before that. He says the Metformin came in an orange pharmacy bottle, NDC/LOT/EXP: not provided, with discard after date 30Apr2023 and manufacturer name Ascend Laboratory. He stopped taking Metformin about two months ago, at the end of May or beginning of Jun. The following information was reported: VACCINATION FAILURE (medically significant), COVID-19 (medically significant) all with onset 21Jul2022, outcome "recovered" (27Jul2022) and all described as "COVID-19 after being fully vaccinated and had boosters twice". The patient underwent the following laboratory tests and procedures: Chest X-ray: (08Aug2022) awaiting results; SARS-CoV-2 test: (27Jul2022) Negative; (04Aug2022) Positive; (08Aug2022) Negative; (22Jul2022) Positive; (22Jul2022) Positive. Therapeutic measures were taken as a result of vaccination failure, covid-19. The patient was treated for COVID-19 with Paxlovid (Lot: GA2268; NDC number of Paxlovid: 0069-1085-30; Expiry Date of Paxlovid: Feb2023) three tablets twice a day orally for five days from 22Jul2022 to 26Jul2022. Clinical course: Patient called to report taking Paxlovid then testing positive for COVID and having rebound effect. Patient said dose was three tablets twice a day orally for five days. Patient tested himself 27Jul2022 and was negative with a home test which he did two tests that were both positive when patient did the positive tests. Patient said the two tests he did for the positive tests were Ellume COVID-19 home test and the Flowflex, which he did on the morning of 22Jul2022, which was when patient tested positive for COVID. He said after taking Paxlovid he tested himself 27Jul2022 with the ones they send from the post office, the COVID-19 home test, which was negative 27Jul2022. He then tested positive with COVID-19 at home test on 04Aug2022. He then tested negative on 08Aug2022 with the COVID-19 home test. He said his rebound symptoms were being dizzy, cough continuing, and perspiring a lot. He did not have a fever for both bouts of COVID, he never had a fever. He has been fully vaccinated, and had boosters twice, all with Pfizer COVID-19 vaccine injections. Caller said his symptoms were being dizzy, cough continually, and perspiring a lot which in both instances began the night before he tested himself, which was one reason that prompted him to test himself. He said the first round started 21Jul2022 when he had symptoms and the second round started 03Aug2022, and now hoped he was done with COVID since he tested negative this morning. Patient clarified that the rebound symptoms after taking Paxlovid started 03Aug2022. He said his treatment was he tried to rest and drank a lot of fluids. He said on his latest round the doctor also before he had COVID, he was experiencing what he thought was bronchitis. He says when he had it, he tested himself for COVID every day for 6 days and it was negative. He came home and tested himself for COVID and it was positive, and he still had cough with phlegm and his doctor gave him Prednisone, which he was still taking. He said Prednisone dose was 10mg tablets, 40 of them, and the regimen was four tablets for four days, then three tablets for four days, then two tablets for four days, then one tablet for four days. He said he was on his fifth day on that, so he has taken 19 of 40 pills so far. Caller said his doctor ordered a chest x-ray which he had that this morning and is still waiting on results. Caller further stated COVID-19 after being fully vaccinated and had boosters twice. Caller says that the information on the vaccine card was handwritten. The first dose of Pfizer COVID-19 vaccine was on 21Jan2021 and all they wrote was LOT: E18982, which looks like it could be a one or a L then numbers 8982. The second dose was given on 11Feb2021 with LOT: E19269 or EL9269. His third dose was given 08Sep2021 and was Pfizer LOT: FC3181 and fourth dose was given 15Mar2022 of Pfizer LOT: FK9894.  The information on the batch/lot number for BNT162b2 has been requested and will be submitted if and when received.