Sex: M
Vaccine: COVID19, COVID19
Symptoms: Respiratory tract congestion, SARS-CoV-2 test, Sinusitis, Sputum discoloured
Clinical narrative: feeling very tired; heavy sinus; chest congestion; chest/back pain near the lower left shoulder blade; chest/back pain near the lower left shoulder blade; a very productive cough with dark green phlegm; a very productive cough with dark green phlegm; I felt terrible; I did another Covid test and this time it was positive.; I did another Covid test and this time it was positive.; slight frontal headache; sore throat; This is a spontaneous report received from contactable reporter (Physician).  A 68-year-old male patient received BNT162b2 (BNT162B2), in Jan2021 as dose 1, single (Batch/Lot number: unknown), in Feb2021 as dose 2, single (Batch/Lot number: unknown), in Aug2021 as dose 3 (booster), single (Batch/Lot number: unknown) and in Feb2022 as dose 4(booster), single (Batch/Lot number: unknown) for covid-19 immunisation. The patient's relevant medical history included: "Type 2 Diabetes" (unspecified if ongoing), notes: taking metformin ER - 2 x 500 mg tablets twice a day and Januvia 100 mg daily.; "chronic lymphocytic leukemia" (unspecified if ongoing), notes: I was diagnosed with chronic lymphocytic leukemia/small lymphocytic lymphoma; "small lymphocytic lymphoma" (unspecified if ongoing), notes: I was diagnosed with chronic lymphocytic leukemia/small lymphocytic lymphoma; "lymph node was removed", start date: Mar2020 (unspecified if ongoing), notes: In Mar2020, the lymph node was removed. Concomitant medication(s) included: METFORMIN ER taken for type 2 diabetes mellitus; JANUVIA taken for type 2 diabetes mellitus. Vaccination history included: Pneumonia vaccine (had a pneumonia vaccine booster and the next morning awoke with an enlarged lymph node the size of a squashed golf ball in my left armpit.), administration date: Jan2020, for Vaccination, reaction: "enlarged lymph node". The following information was reported: HEADACHE (non-serious) with onset 19Apr2022, outcome "recovered", described as "slight frontal headache"; OROPHARYNGEAL PAIN (non-serious) with onset 19Apr2022, outcome "recovered", described as "sore throat"; DRUG INEFFECTIVE (medically significant), COVID-19 (medically significant), outcome "recovered" (27Apr2022) and all described as "I did another Covid test and this time it was positive."; FATIGUE (non-serious), outcome "unknown", described as "feeling very tired"; SINUSITIS (non-serious), outcome "unknown", described as "heavy sinus"; RESPIRATORY TRACT CONGESTION (non-serious), outcome "unknown", described as "chest congestion"; CHEST PAIN (non-serious), BACK PAIN (non-serious), outcome "unknown" and all described as "chest/back pain near the lower left shoulder blade"; PRODUCTIVE COUGH (non-serious), SPUTUM DISCOLOURED (non-serious), outcome "unknown" and all described as "a very productive cough with dark green phlegm"; FEELING ABNORMAL (non-serious), outcome "unknown", described as "I felt terrible". The patient underwent the following laboratory tests and procedures: Blood test: (unspecified date) Normal, notes: My blood tests have been normal; SARS-CoV-2 test: (unspecified date) Positive, notes: I did another Covid test and this time it was positive; (20Apr2021) Negative. Therapeutic measures were taken as a result of drug ineffective, covid-19, headache, oropharyngeal pain, fatigue, sinusitis, respiratory tract congestion, chest pain, back pain, productive cough, sputum discoloured, feeling abnormal. Clinical course included that On Sunday, 17Apr, Patient and his wife attended a meeting with neighbors. Also attending were their son, daughter-in-law and two grandsons. On Monday, 18Apr, their neighbor notified them that their son and daughter-in-law tested positive for Covid-19. In the afternoon on Tuesday, 19Apr, patient experienced a slight frontal headache and sore throat for about an hour each. The next morning (Wednesday) patient did a rapid Covid test because he was scheduled to undergo cataract surgery the next day on Thursday. The test was negative. patient and his hosted their community dinner Wednesday evening with 35 people in attendance including the wife of the neighbors whose dinner we attended on Sunday. patient led the dinner and interacted with most of the people. In addition to leading the dinner, they worked very hard serving the dinner and cleaning up afterwards. During their drive home, patient started feeling very tired and thought it was a result of the work done during the dinner. patient did another Covid test and this time it was positive.patient notified the Wills Eye Surgery Center about the test result and his surgery was cancelled. The next morning (Thursday), his condition deteriorated very rapidly. he was amazed at how rapidly his condition went from bad to worse. patient  experienced very heavy sinus and chest congestion, chest/back pain near the lower left shoulder blade and a very productive cough with dark green phlegm. There was no headache, sore throat or fever. patient felt terrible.Patient contacted his physician, (name withheld), MD, at Health in (address withheld), and described his condition. He prescribed Paxlovid, benzonatate and albuterol inhaler. patient took the first Paxlovid dose in the afternoon on Thursday, 21Apr. Patient tested negative for Covid on Wednesday, 27Apr. Patient strongly believes that if he was not prescribed Paxlovid, he would have been hospitalized and possibly placed on a respirator. he feel very lucky that he was immunized with the Pfizer Covid vaccines and treated with Paxlovid. Thank you for your efforts advocating vaccination and Covid treatments.    The information on the batch/lot number for BNT162b2 has been requested and will be submitted if and when received.; Sender's Comments: Based on possible temporal association the causal role of BNT162B2 Vaccine cannot be excluded for reported events .Case will be reviewed further on receipt of FU information  The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to regulatory authorities, Ethics Committees, and Investigators, as appropriate