Age: 65.0
Sex: F
Vaccine: COVID19
Symptoms: Bone disorder, Electrocardiogram, Glomerular filtration rate, High density lipoprotein, Left ventricular hypertrophy
Clinical narrative: osteoporosis; reduced kidney function; left ventricular hypertrophy; This is a spontaneous report from a contactable consumer (patient). A 65-years-old female patient received the second dose of BNT162B2 Pfizer-BioNTech COVID-19 mRNA Vaccine via an unspecified route of administration on 18Mar2021, at 65 years of age, (Batch/Lot Number: EP7534) as single dose for COVID-19 immunization. Medical history included headache from 04Apr2021 and ongoing, for which a MRI-Brain was performed on 30Jul2021 follow up with Dr is scheduled on 31Aug2021 and family history of stroke in Aug2009. Historical vaccine included the first dose of BNT162B2 Pfizer-BioNTech COVID-19 mRNA Vaccine Lot# EL9266) administered on 25Feb2021, after which her hair has been shedding and falling out. The patient didn't receive any other vaccination within the previous 4 weeks. Concomitant medications included telmisartan 40 mg tablets by mouth; ubidecarenone (CO Q-10) 10 mg capsule; amlodipine besilate 10 mg tablet by mouth; omeprazole 20 mg capsule by mouth; fluticasone propionate 50 mcg/actuation nasal spray, acetylsalicylic acid (ASPIRIN) 81 mg by mouth and omega-3 fatty acids-fish oil 360-1,200 mg cap, all taken for an unspecified indication since an unknown date and benzalkonium chloride;sodium chloride (ALIVE) tablet taken for an unknown indication since 30Jun2020. On 15Apr2021 an abnormal ECG was detected: Moderate voltage criteria for left ventricular hypertrophy (LVH), may be normal variant, Normal sinus rhythm, Non specific T wave abnormality. Lipid panel performed on 01Jun2021 showed high LDL and a high cholesterol. A suggestion to correct it with nutritional and exercise was made. Chemistry also showed a reduced kidney function, assessed as medically significant. Moreover the patient experienced osteoporosis, assessed as medically significant. It was diagnosed through a DXA Bone density exam performed on 14Jul2021 9:14 AM for asymptomatic menopausal state. Lumbar and hip (proximal femur) bone densitometry was performed using the Hologic Bone Densitometry Unit. Osteopenia in the lumbar spine, T score is -1.3 and osteoporosis in the left femoral neck, the T score is -2.7 were detected. Based on FRAX assessment the 10 year probability of major osteoporotic fracture is 14%. Ten year risk for hip fracture is 3.4%. The patient underwent lab tests and procedures which included Spine (L1-13) BMD: 0.874 g/cm2 (Young Adult comparison, T score: -1.3, Age-Matched comparison, Z score: 0.5) - L4 was omitted as it was falsely elevated due to sclerotic and degenerative change. Left Hip Total BMD: 0.869 g/cm2 (Young Adult comparison, T score: -0.6, Age-Matched comparison, Z score: 0.7), Left femoral neck BMD: 0.552 g/cm2 (Young Adult comparison, T score: -2.7, Age-Matched comparison, Z score:-1.1). Relevant lab test collected on 01Jun2021 also included Glucose 103 mg/dl (standard range- 65-99 mg/dl) (for someone without known diabetes, a glucose value between 100 and 125 mg/dl is consistent with prediabetes and should be confirmed with a follow up test); Creatinine 1.01 mg/dl (standard range 0.50- 0.99 mg/dl), GFR MDRD Non Af Amer- 58 ml/min/1.73m2; GFR MDRD  Af Amer- 68 ml/min/1.73m2 (standard range > or= 60 ml/min/1.73m2), calcium- 10.2 mg/dl (standard range 8.6-10.4 mg/dl), cholesterol, total- 217 mg/dl (standard range < 200 mg/dl), HDL- 52 mg/dl (standard range > or= 50 mg/dl ), LDL calculated- 144 mg/dl (Reference range < 100 for primary prevention), Non-HDL Chol (LDL + VLDL) 165 mg/dl (calc) (standard range < 130 mg/dl (calc)). At the time of the report the events outcome was unknown.  Follow-up attempts are completed. No further information is expected.