Age: 64.0
Sex: M
Vaccine: COVID19
Symptoms: Blood gases, Blood test, Eyelid ptosis, Pain in extremity, SARS-CoV-2 test
Clinical narrative: ptosis of right eye; leg pain (both legs); This is a spontaneous report from a consumer. A 64 years old male patient received BNT162B2 (PFIZER-BIONTECH COVID-19 MRNA VACCINE), dose 2 via an unspecified route of administration on 18Mar2021 (Lot Number: EN6208) as SINGLE DOSE (at age of 64 years old) for covid-19 immunisation.  Medical history included hypertension from an unknown date and unknown if ongoing , anxiety from an unknown date and unknown if ongoing, restless legs syndrome from an unknown date and unknown if ongoing, sleep disorder from an unknown date and unknown if ongoing, Neurological Disease from an unknown date and unknown if ongoing, spinal fusion from an unknown date and unknown if ongoing (had 2 spinal fusions. One spinal fusion was of the cervical spine with hardware, and the other spinal fusion was of the lumbar spine with hardware). Concomitant medications included amlodipine besilate, atorvastatin calcium (CADUET) strength 5mg/20mg taken for an unspecified indication, start and stop date were not reported; lisinopril taken for an unspecified indication, start and stop date were not reported; carvedilol taken for an unspecified indication, start and stop date were not reported; tadalafil 5 mg taken for enlarged prostate, start and stop date were not reported; alprazolam (XANAX) 0.5 mg taken for anxiety, start and stop date were not reported; ropinirole (ROPINIROLE) taken for restless leg syndrome, start and stop date were not reported; clonazepam taken for sleep disorder, start and stop date were not reported; carbidopa, levodopa 50mg/200mg taken for an unspecified indication, start and stop date were not reported.  Historical vaccine information included  BNT162B2, dose 1 on 28Feb2021 (Lot Number: EN6205) dose 1, for covid-19 immunization at age of 63 years old. He received second dose on 18Mar2021; 30 days later 18Apr2021 woke up at 5 A.M., noticed ptosis of right eye on 18Apr2021. Concerned she took him to the hospital where he was assessed for stroke, TIA, all tests were negative. Consumer states, "my fiance was hospitalized over the weekend, we do feel it was exactly 30 days after second dose of Pfizer dose, from what I read in medical articles. I see that there were some cases of Palsy experienced by people in clinical trial. He is currently at home. He was in the hospital (emergency room)from 7am on 18Apr2021 and left at 3:50pm that same day against medical advise due to they did not have a neurologist. They wanted to admit him and transfer him to another facility because they didn't have a neurologist available. She clarified her fiance's adverse event as ptosis of his right eye.  She said her fiance had diagnostics and blood work performed while at the Emergency Room. She said she wasn't positive if the blood work performed was a CBC and basic blood chemistry, but the blood work results were normal. She said the hospital she brought her fiance to did not have a neurologist on staff. She said the hospital wanted to admit and transfer her fiance to a specialized hospital with a neurologist on the premises. She said her fiance's condition did not worsen while at the Emergency Room, but she felt her fiance was not being monitored closely, and was not getting any care. She said since her fiance was not receiving anything at the Emergency Room, and the Emergency Room didn't have the bandwidth to address his issues, and nothing was done to transport him to another hospital, her fiance left the Emergency Room against medical advice (AMA). She said her fiance went to a neurologist on Monday (19Apr2021). Emergency Room Visit Treatment: Stated her fiance was given Oxycodone while at the Emergency Room. She said she did not know the Oxycodone dose, NDC, Lot, and Expiration Date. She said the Oxycodone was administered for leg pain (both legs) caused by a pre-existing condition her fiance had. She said her fiance normally took Ropinirole for his leg pain. Consumer reported her fiance had follow-up testing done at the neurologist on Monday (19Apr2021), and was waiting for the test results to come back. She clarified the neurologist was doing the follow-up testing to confirm or rule-out a diagnosis of Myasthenia Gravis. Consumer reported when she took her fiance to the Emergency room she thought he was going to be assessed for a possible TIA or stroke, but when it was mentioned her fiance may have Myasthenia Gravis, it was equally concerning. Neurologist Visit Treatment: She stated the neurologist prescribed Pyridostigmine 60mg on Monday (19Apr2021) for her fiance to start taking while the doctor waited for the blood work and repetitive nerve conduction study results to come back. She said the doctor's logic was to take the Pyridostigmine 60mg, and see if the ptosis resolved, and if the ptosis resolved the doctor would know the cause of the ptosis. She said her fiance's right eye ptosis had not improved, changed, or resolved since he started taking the Pyridostigmine 60mg. She said she did not have the Pyridostigmine 60mg NDC, Lot, and Expiration Date. The patient underwent lab tests and procedures which included  blood gases (ABG): unknown on 18Apr2021, Vital capacity: normal  on 18Apr2021, Blood test: unknown on 18Apr2021, COVID-19: negative on 18Apr2021; vital signs measurement: normal on 18Apr2021 . Therapeutic measures were taken as a result of ptosis of right eye. Outcome of the event ptosis of right eye was not recovered. Outcome of the event leg pain (both legs) was unknown.