Age: 62.0
Sex: M
Vaccine: COVID19
Symptoms: Pyrexia, Red blood cell sedimentation rate increased, SARS-CoV-2 test, Vaccination site reaction
Clinical narrative: General mailaise; side effects for 7 weeks since getting the second dose of Moderna; night sweats/Night sweats still occur; severe throbbing headaches/The headaches are not as severe, but still continue; extreme fatigue; low grade fevers; This case was received via an unknown source (no reference has been entered for a health authority or license partner) on 08-Jun-2021 and was forwarded to Moderna on 08-Jun-2021.    This spontaneous case was reported by a consumer and describes the occurrence of MALAISE (General mailaise), VACCINATION SITE REACTION (side effects for 7 weeks since getting the second dose of Moderna), NIGHT SWEATS (night sweats/Night sweats still occur), HEADACHE (severe throbbing headaches/The headaches are not as severe, but still continue) and FATIGUE (extreme fatigue) in a 62-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch nos. 018B21A and 014M20A) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below.     The patient's past medical history included Lyme disease (Lyme disease).   On 18-Mar-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 15-Apr-2021, received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) dosage was changed to 2 dosage form. On an unknown date, the patient experienced MALAISE (General mailaise), VACCINATION SITE REACTION (side effects for 7 weeks since getting the second dose of Moderna), NIGHT SWEATS (night sweats/Night sweats still occur), HEADACHE (severe throbbing headaches/The headaches are not as severe, but still continue), FATIGUE (extreme fatigue) and PYREXIA (low grade fevers). The patient was treated with PARACETAMOL (TYLENOL) ongoing since an unknown date for Adverse event, at a dose of 1 dosage form and IBUPROFEN ongoing since an unknown date for Adverse event, at a dose of 1 dosage form. At the time of the report, MALAISE (General mailaise), VACCINATION SITE REACTION (side effects for 7 weeks since getting the second dose of Moderna), NIGHT SWEATS (night sweats/Night sweats still occur), HEADACHE (severe throbbing headaches/The headaches are not as severe, but still continue), FATIGUE (extreme fatigue) and PYREXIA (low grade fevers) had not resolved.      DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On 03-May-2021, Full blood count: unknown (Negative) CBC. On 10-May-2021, SARS-CoV-2 test: no - negative covid-19 test (Negative) Co-vid test negative. On 14-May-2021, Blood culture: unknown (Negative) blood cultures-Negative. On 14-May-2021, Computerised tomogram: negative (Negative) CT scan of head-Negative. On 14-May-2021, Culture urine: unknown (Negative) Urine cultures. On 20-May-2021, C-reactive protein: 162.1 (High) C-reactive protein: 162.1mg/L. On 20-May-2021, Parasite blood test: negative (Negative) Babesia. On 20-May-2021, Red blood cell sedimentation rate increased: 35 (High) Sedimentation rate: 35mm/hr.         Concomitant medications not provided. Patient lab data included:  5/20/2021  CMV DNA Quant, toxoplasma gondii (igg and Igm).     5/3/2021    All Negative: Lyme, metabolic panel, CBC, urine reflex Fevers range from 99.4 to 100.6 F and are less frequent.   Most recent FOLLOW-UP information incorporated above includes: On 30-Jun-2021: Follow-up report received on 30-JUN-2021 Added patient demographics, lab data, added treatment medication. Updated event outcome as not recovered not resolved.