Age: 61.0
Sex: M
Vaccine: COVID19
Symptoms: Pyrexia, SARS-CoV-2 antibody test, Vaccination site mass, Vaccination site pain, X-ray
Clinical narrative: stiff neck and knotted muscles happened only this time in the right side of his neck; Everything was sore, neck; spaciness; Everything was sore; right shoulder did get sore right away eventually; Slight fever/ slight elevated temperature; reinvigorated left shoulder injection site soreness; felt like someone beat him with a baseball bat; almost like he couldn't move; muscular soreness; hard for him to move; slight bulbiness across the whole right injection site, underneath, no external view; feels a little fluish, like he is coming down with something/ feeling like he can't get off the couch; His O2 saturations were a little higher than normal; He had soreness especially neck and arms; This is a spontaneous report from a contactable consumer (patient). A 61-years-old male patient received second dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, solution for injection; Batch/Lot Number: EW0151; Expiration Date: 30Jul2021; NDC number: unknown) via an unspecified route of administration on 15Apr2021 at 10:00 (at the age of 61-years-old) in right arm as a single dose for covid-19 immunization. Medical history including any illness at time of vaccination) included migraines (he had history of migraines and his mother had a history of it as well), reactive airways disease, occasionally high iron, erratic heartbeat about 5 years ago. He mentioned he had to wear a Holter monitor and wore for 24hrs and one 48hrs. The 24hr got 200 events and the 48 half of those in 48hrs. He was on beta-blockers for a while. He has a history of leaky gut type syndrome and he and his wife had been eating organically and staying away from processed food; taking supplements which had to do with anti-clotting and blood thinning attributes like fish oil and turmeric. He does take an 81 mg aspirin from time to time and has taken 2 in the last couple of days. He does not normally take them that often. His blood clotting factors is probably suppressed more than the average citizen. He stated that clinic found hole between his two heart chambers that he had probably since birth. Caller stated that 5 years ago he had sudden onset heart palpitations, and he still gets a flutter once in a while, but it had subsided and cannot determine where it came from. Just prior to covid starting in August he was cutting grass and ran across possible mold in grass. He coughed for like three days. His sinuses got infected, went down in his lungs and was treated with antibiotics for 3-5 rounds. He was on Doxycycline and something else that was not clearly stated and not clarified further. This generated a presumed pneumonia confirmed by x-ray. After treated with antibiotics it was probably when pneumonia went away. However, he had problem that continued all the way through January. He was coughing a lot. He passed out on the floor and could not breathe.  His oxygen sets dropped to 80's so coughing for hours at a time; multiple hospitals to culture and came with two different kinds of molds non-human pathogens, things started getting better, February went to reactive airway disease, lungs overreact. He had been to the ER twice with eye issues. He had German measles, bronchial hyperreactivity, occasionally high iron, erratic heartbeat in past. Family medical history relevant to adverse event included cancer on dad's side of the family. Concomitant medications included doxycycline (DOXYCLINE [DOXYCYCLINE]) taken for an unspecified indication, start and stop date were not reported; ibuprofen (IBUPROFEN) taken for migraine, start and stop date were not reported. He had not taken it often within the last year. He may had taken two doses of the 200mg within a year. Trying to stop due to stomach issues. Caller does mention that a couple of hours before both doses of the Pfizer covid-19 vaccine he took half of a pill of over the counter generic 12-hour Claritin. The patient's historical vaccine included first dose of BNT162B2 (COVID Pfizer vaccine) on 25Mar2021 at 10:00 in left arm for covid-19 immunization. Caller stated within seconds, instantaneously, he felt it shoot up his neck on the left side and his muscles knotted, which caused him to have a stiff neck. It stayed that way, like if you sleep on your neck wrong all night.  It was not the MRNA he had a problem with, but the carrier components he felt immediately reacting to. On the date he goes for vccination he had an O2 sensor on and within ten minutes he felt mild spacy and lightheaded, kind of dizziness. Then he was ok the next day. Then on the third day the mild spacy, dizziness, listlessness came back slightly, then that was it. Confirmed the spaciness and listlessness went hand in hand. Caller stated he recovered fully from all the events of first shot by 29Mar2021. Caller does state that he had O2 sensor on him at the time of immunization and his O2 levels stayed normal. Caller stated that his wife had to drive them home after the first dose because he felt a little fist bolding, like not seeing quite exact, spacy kind of like, something foreign feeling. Caller stated that prior to getting the first shot he was fairly active and attributed these events to that and kind of dismissed them because thought over did something. He does have pre-covid lung issue. Caller mentioned in Sep2019 or Oct2019 when he had X-Ray that showed Pneumonia, it was all concluded by Jan2020 somewhere around there. His local doctor placed him on generic singular a small dose. He weaned off quickly, it cured him within a week in regard to hacking, wheezing, bronchial issues. There were so many FDA warnings and things. Caller received second dose of Pfizer covid-19 vaccine on 15Apr2021 at 10:00 in his right arm, his reaction was little more delayed than the first dose. Caller stated within 20 min exactly the same stiff neck and knotted muscles happened only this time in the right side of his neck. Caller does note that there was no spaciness right away with the second dose. His O2 saturations were a little higher than normal. He stated that him and his wife were stuck around for an hour monitoring everything before he left the shot facility. He felt ok and at the time he thought he would drive but went ahead and let his wife drive home. Right about 5 hours later he started experiencing the spaciness like before with the first shot, but at 7 hours after getting the shot he felt like someone beat him with a baseball bat. Everything was sore, especially neck and arms. Both times his shoulder did not get sore right away, but last night his right shoulder did get sore right away eventually. It was hard for him to move. He also reported that where he got the injection there was slight bulbiness, it was swollen slightly. Just a little bit puffy like in the muscle. The event did not require emergency room and physician office visit. He confirmed he had no chills, but he had slight elevated temperature in morning, may had been up 1 degree from normal and his normal is 1 degree below normal, so maybe up to 99 or 100 and dropped off pretty quick. He ate normal breakfast and things like that and moving around more and thought he got a good wind, but then got listless in afternoon while he was waiting on hold for the call, he got feeling like he can't get off the couch. He felt a little better later. He had a feeling that tomorrow may be pretty ok. He felt little flui-sh, like a light flue, like he's coming down with something today. He stated it was like the dose he got reinvigorated left shoulder injection site soreness from the first dose. He can't remember being hardly sore on the left side after the first dose. He thinks maybe it started on the third day. It was worse on his first shot site after his second shot like a residual effect. Caller also adds that him or his wife didn't drink four days after the first dose of Pfizer covid-19 vaccine and for the second one didn't drink any alcohol four days before or four days after the shot. He got the shot due to pre-existing possibilities; if he got covid he may not fair well. Caller stated he had heard stories that the vaccine was not affective against the south African variant but everything on TV says that it was. He may have antibodies reacting to PEG that he didn't have before. Caller stated a year ago he was looking at all the research on various vaccine start-ups, about 8 months ago chose Pfizer as one to pursue due to technical background. He didn't trust the other one because of some of the ways they were doing it. He mentioned he did some research on some of the new findings that he feels should have been given to public before distribution. Caller states he has been reading about use of PEG in shots and other Rx prescriptions. He has concerns are generated around IgG, IgM, and IgE and immune responses and antibodies generated through PEG. Caller stated he has used the questionnaire that we had and asked if any reactions to Polyethylene Glycol and he has not because he has had scopes and Mirlaxx prepartion and things like that, did not think anything about it. Caller stated that he has researched that Phenylethylene glycol when used internally sometimes generates internal anaphylactic response and he could have had a response due to use over time. He mentioned he could have a response due to a build up over time, an antibody response. If he had known ahead of time would have thought more about not getting the shot. He did anyway and got the second one yesterday. Caller also has concerns about the Johnson and Johnson and the overseas one clotting factor disruptions. He read about the mechanism, the protein from the Coronavirus is being produced by MRNA. Looks like that is one of things that trigger clotting factor disruption and activating new platelets and therefore, possible clotting. He would like to implore or request Pfizer not to use things like PEG that are not natural compounds in order not generate antibody response reactions. Caller stated if there was a chance that he had generated antibodies against PEG, and he may not get any booster shot if there is no change. Stated if there is no change it can cause a reaction on his part. He continued to reiterate he does not like the fact that PEG is used. He will not use Miralax, laxative for anything knowing what he knows from the Pfizer COVID-19 shot. The patient underwent lab tests and procedures which included sars-cov-2 antibody test: negative on 01Mar2021 and x-ray: pneumonia on an unknown date. He wanted to make sure he didn't have antibodies or exposed to covid prior to the shot. The outcome for the events vaccination site pain, myalgia, movement disorder, shoulder pain, vaccination site mass was not resolved and for all other events was unknown.  No follow up attempts are possible, no further information is expected.