Age: 53.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Stomatitis
Clinical narrative: This is a spontaneous report from a contactable consumer. A 53-year-old male patient received bnt162b2 (COVID-19 VACCINE, lot number: EN6203; expiration date: Jun2021), dose 1 via an unspecified route of administration on 27Feb2021 18:00 as single dose for covid-19 immunisation. Medical history included ongoing lyme disease. There were no concomitant medications. The patient went through post- vaccination especially because he has Lyme disease. He has had this pre-existing autoimmune disease for 8, almost 9 years, he wants to add this information to the database. Caller states the first shot he would say was kind of catastrophic, the second shot, he will go into. Caller states the second shot, he showed up at the military vaccination place locally and they actually declined his ability to get it with them because of his first reaction even though he had the go ahead from his Lyme specialist and primary doctors. Caller states because of this, he went after four weeks instead of three and he went to a high risk clinic to protect him from anaphylaxis. He has received both doses, the first dose was horrendous and the second was quite easy. Caller states no reaction whatsoever with the second, though he still has remaining symptoms. Reporter Details: Caller states his legal name is (Name), he goes by (Name). Caller states he would prefer if company contacted him and also so that maybe they can warn people with autoimmune or Lyme that the first one is going to be kind of rough. Caller states he works with the public. Prescribing Healthcare Professional: Caller states unsure of email address. Caller states the only thing missing off the initial story is that all in all, the second shot was really good. Caller states he does have some very lingering issues still that he is going to be seeing the Lyme specialist about. Caller states the first dose, it's pretty intense. Caller states the second one, he had fatigue and neuropathy from the stupid autoimmune stuff. Caller states there is residual symptoms, but nothing like the initial ones. Caller states what he did was he just jotted some notes down about every third or fourth day up until the second shot just to detail each symptom. Caller states he only wrote about 5 days worth of little sentences. Caller states 27Feb2021, the first dose, it was a Saturday so by Monday 29Feb2021, it started with itching, burning rashes, so like a visible rash on his chest with raised bumps, neuropathy- shooting pains in his fingers and toes that feels like bugs are crawling all over him, headache, fatigue, and dizziness. Caller verifies all of these symptoms actually began on 01Mar2021. Itching, burning rashes: Caller states he would say they lasted about 2-3 weeks because he went to the walk-in to have them check and called his primary doctor and went into his primary and had him check. Caller states it ended sometime in Mar2021 and he has recovered completely. Neuropathy: Shooting pains in his fingers and toes: Caller verifies it began 01Mar2021. Caller states he would say he still has about 20% left. Caller states it is hard to sleep at night because he still gets itching and burning and stuff. Caller states it is persisting, but certainly not as bad. Headache: Caller verifies it started 01Mar2021. Caller states it ended Mar2021 and has recovered completely. Fatigue: Caller states began 01Mar2021. Caller states this is one of the bad ones he would say. Caller states he still, he would like to go for a walk or work out and he barely has the amount of energy to work let alone the others. Caller states he can't workout or walk. Caller states if he goes up and down stairs, he's exhausted. Caller states that's definitely a lasting one. Caller verifies it is ongoing, persisting. Dizziness: Caller verifies it began on 01Mar2021 and is ongoing. Caller states when he walks he literally cannot turn his head quickly or he feels like he's going to throw up or pass out. Caller verifies it is persisting. Caller states he would say about 4 or 5 days later from getting the first shot, this was really interestingly weird, he had mouth sores that wouldn't heal and debilitating malaise and fatigue. Caller states malaise so bad he couldn't get through work, he could barely work. Caller states the mouth sores were so weird. Caller states everything he is telling company he has read about online. Caller states he has had canker sores from low immunity, but this was on the tip of his tongue, either side of the tongue tip, it came and went three or four times through the entire month. Caller states it was like his immune system was on the edge of crashing, then he would sleep a lot more. Caller states he would do whatever he could do to make it come back. Caller verifies this debilitating fatigue is different than overall fatigue that began 01Mar2021. Caller states the debilitating malaise began 04Mar2021 or 05Mar2021. Debilitating Fatigue; Debilitating Malaise: Caller states the debilitating fatigue also began 04Mar2021 or 05Mar2021. Caller states it is acute. Caller states ended sometime in Mar2021. Caller states recovered completely but is still left with some fatigue. Caller states recovered with lasting effects maybe. Caller says the other one, he could barely get up, he could barely work, he literally couldn't function. Caller states the overall fatigue has not left, it's ongoing. Mouth sores that won't heal: Caller states began around 004Mar2021 or 05Mar2021 and stopped sometime in Apr2021, it took about a month. Caller states he recovered completely. Caller states he just wrote what happened down about every 2 days up until 14Mar2021. Joint Pain: Caller states literally every single joint in his body was killing him and felt inflamed. Caller states it began around 03Mar2021 or 04Mar2021. Caller states joint pain is ongoing, but has improved. Air Hunger, shortness of breath upon exertion: Caller states if he went up and down a few stairs, he would breathe almost as if he was having an asthma attack, it was shortness of breath upon exertion and started about four days after. Caller states it began around 05Mar2021. Caller states he actually had it this morning, felt like he just walked up a flight of stairs. Caller states he is very physically fit, so that should not happen. Caller states it's ongoing and has improved. Numb Extremities: Caller states a week later from 01Mar2021 he had numb extremities. Caller states he started being very aware of the fact that his fingers and toes were starting to lose feelings on 08Mar2021. Caller states it resolved within a week on 15Mar2021. Caller states it was a weird sensation that happened for a while but is completely resolved now. Body Temperature Regulation Issues: Caller states two days later, he had body temperature regulation issues. Caller states he was cold when he should have been hot and hot when he should have been cold. Caller states began around 03Mar2021/04Mar2021 and is ongoing, but not terrible, it's probably the least of the issues and has improved. Heart was pounding out of his chest; face was flushed: Caller states a day or two later, his heart was pounding out of his chest and his face was flushed to the point where people were asking if he was okay. Caller states he felt like he got a quick burst of a run and then stood still. His face was visibly red and very aware of his heart beating out of his chest and this is with no exertion. Caller states he was laying on the couch and he could feel his face flush while doing nothing basically. Caller states began 02 or 03Mar2021 and just stopped a week ago around 12Apr2021. He recovered completely, for now, it seems. Caller states he went to (Clinic name) on (Address), he doesn't have the doctors name, it was a walk-in. Caller states they literally said no big deal, it's all side effects of the vaccine, they just said he's fine. Caller states they simply recommended anti-inflammatories, Tylenol, which was smart and he wishes he thought about it. They also recommended Benadryl to stop the reaction. Caller states it was very helpful, the Benadryl really helped a lot. Caller states there was also a good amount of insomnia because of all the symptoms, it would be close to impossible to sleep. Insomnia: Caller states it seemed to get worse, started a week later because it  was getting disconcerting to him so he couldn't sleep. Caller states it started 08Mar2021 and have had that on and off with Lyme. Caller states has struggled for years, is ongoing and is persisting. Caller states on 14Mar2021, he couldn't sleep, couldn't get out of bed, completely weak and dizzy, his left leg and quad was spasming like when he had Lyme's, left knee itches, tingles, and burns and that's where he got bit by the tick and that's when he had his symptoms when he was acute. Caller states it resolved within 3 weeks after the initial onset of the shot. Caller states when he had Lyme initially, that's what he experienced, his left knee swelled, burned and itched, his left knee cap. Caller states ended 17Apr2021. Caller states its a situation where some of those are still there because of Lyme and some are gone. Caller states the knee cap stuff and can't get out of bed was gone on 17Apr2021. Caller states he has recovered completely. Caller states he still is weak and dizzy and his left leg and quad are still spasming, but it's better and is improved. Caller states on 20Mar2021, his left knee cap hurt, was twitching and tight, his left toe was numb, felt like something is chewing on his toe with a sensation of worms under the skin and sleep disturbances. Caller verifies the sensation of worms under the skin and something chewing on his toe is all related to neuropathy, which is still there. Caller states he had written down that on 20Mar2021, he was supposed to get his second shot at 1800, but was denied due to side effects he was experiencing and was rescheduled for 31Mar2021 at a local high-risk clinic. Caller states on 22Mar2021, he slept good, but was fairly weak all day. caller states he took a shower mid-afternoon, and couldn't get off the couch. Caller states basically all he did was take a shower and threw himself on the cough the whole day. Caller states he has written that he has the sensation of ants crawling over the top of his back, no desires to go outside, and light sensitivity. Caller verifies the ants crawling over the top of his back was also neuropathy, and he recovered completely within 3 weeks. Light Sensitivity: Caller states throughout the whole thing, had it today and is still ongoing and persisting. Caller states began sometime in Mar2021, its been the whole time. Caller states 28Mar2021, he only slept 6 hours and woke up completely fatigued, could not get out of bed until 2:00 in the afternoon, has a complete loss of appetite, had a drink and 2 eggs and laid down, couldn't move until 1930. Caller states got up, had a nutrition shake, he wasn't desiring solid foods whatsoever, had 100% malaise, fatigue, no appetite, and was dizzy. Loss of appetite: Caller states he has lost 7 pounds since the first shot. Caller states he wasn't really interested in eating. Caller states he has a natural desire to eat and nothing sounded good. Caller states started Mar2021, is ongoing, and has improved. Caller states 31Mar2021, he got the second shot, he had a little bit of irritation, tingling and burning at site and definitely a flushed face throughout the day, almost like a sunburn. Caller states he was joking with clients and said the first shot killed him and the second shot cured him. caller states after the second shot, he is 80% better but can list the remaining symptoms. Caller states what he is left with is fatigue, he does not have any energy to do anything other than work, sleep issues, neuropathy, and dizziness. Dizziness: Caller states the dizziness has been consistent and goes with the sleeplessness, ongoing since Mar2021 and is persisting. Irritation, tingling, and burning at injection site: Caller verifies the irritation, tingling, and burning is at the injection site of the second dose. Caller states it happened within a few hours on 31Mar2021 and resolved within a week on or around 07Apr2021. Covid Vaccine: First Dose: Caller verifies he received the injection in his left arm around 1800. Caller unsure of NDC. Covid Vaccine: Second Dose: Caller verifies he received the second dose on 31 Mar2021. LOT: ER8730, Expiry Date: They didn't write that down so caller unsure. NDC: Caller unsure of NDC. Caller unsure of dosage given. Caller states was given via injection in his right arm around 1300 or 1330. Covid Vaccine: Indication: Caller states first off he owns a business, he did it to be responsible to the public. Caller states he wants his business to appear as safe and compliant as possible. Caller states he definitely was afraid because of the Lyme disease. Concomitant Products: Caller states he made sure he did nothing before purposefully. Test Results: Caller states after the first shot, he went to (Name) family physician, they did a lot of blood work trying to make sure his inflammatory markers weren't going up, to make sure he wouldn't have issues. Caller states the good news was he was great, everything looked normal, there was nothing crazy in the blood work. Caller states they though the shots would have triggered an autoimmune response of Lyme. Muscle/Joint: He reports a bit of muscular/joint pain in the area where the shot is, if he goes to reach  The outcome of the event "itching, burning rashes, like a visible rash on his chest with raised bumps", "headache", "can't workout or walk", "exhausted", "immune system was on the edge of crashing", "immune system was on the edge of crashing", "face was visibly red" was resolved in Mar2021; the outcome of the event "debilitating malaise" was resolved with Sequel in Mar2021; the outcome of the event "Numb Extremities" was resolved in 15Mar2021; the outcome of the event "mouth sores" was resolved in Apr2021, the outcome of the event "face was flushed" was resolved in 12Apr2021; the outcome of the event "couldn't get out of bed" "left knee itches, tingles, and burns" was resolved in 17Apr2021, the outcome of the event Back disorder was unknown, the outcome of the event "complete loss of appetite", "Joint Pain", "Body Temperature Regulation Issues", "barely has the amount of energy to work let alone the others/Weak" was resolving, the outcome of the other events was not resolved.