Age: 74.0
Sex: M
Vaccine: COVID19
Symptoms: Headache, SARS-CoV-2 test positive, Sinus disorder
Clinical narrative: COVID-19 virus test positive; COVID-19 virus test positive; cough; weak; headache; sinus issues; tiredness; This is a spontaneous report from a contactable female consumer. This 74-year-old male consumer (patient) reported that he received his first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 mRNA VACCINE, Solution for injection, Batch/Lot number: EL3246) via an unspecified route of administration into the right arm on 18Jan2021 (at the age of 74-year-old) as single dose for COVID-19 immunisation. The patient medical history included ongoing overweight, blood pressure, thyroid and diabetes. On an unspecified date, COVID 19 virus test was positive. Concomitant medications were not reported. The patient reported that he came down with the Covid-19 virus on 01Feb2021 and tested positive for the Covid 19 virus on 03Feb2021 with the swab in his nose and he received his positive results in the afternoon on 04Feb2021. He started having symptoms on 01Feb2021. He had a cough, headache, sinus issues and tiredness. He had no fever. His symptoms only lasted until about 05Feb2021, except for the tiredness. He was tired and weak for about 6 weeks. The caller received his second Covid 19 vaccine in the right arm on 19Feb2021. The needle did not hurt for his second vaccine but the injection part hurt for a good 24 to 36 hours. He meant it hurt, just at the injection site and he did not feel the needle, but he felt pressure at the injection site and it started hurting immediately. That night, 19Feb2021, he had a little fever and he started coughing again and he had a headache. He remembers because he got up in the middle of the night. The next morning, 20Feb2021, the fever, coughing and headache were gone. Only his injection site was bothering him. He takes medicines but does not think his medications are relevant. He has routine blood work done every 6 months and his doctor told him he was healthy. He reported he does not exercise and both he and his wife were tested for the Covid 19 virus at a 360 degree mini-hospital. No history of all previous immunization with the Pfizer vaccine considered as suspect (or patient age at first and subsequent immunizations if dates of birth or immunizations are not available) and no vaccines administered on same date with the Pfizer vaccine considered as suspect. No following prior vaccinations. The reporter called for his wife who had a history of cancer. She received her first dose of the Covid 19 vaccine on 18Jan2021. Then she and the reporter both tested positive for the Covid 19 virus. He got his second Covid 19 vaccine. His wife was not able to get her second dose and enquired when will she be able to get her second vaccine. She was hospitalized and was still following up with her doctors getting chest x-rays because her doctor said the Covid 19 virus was still in her system even though she was not having any symptoms. Before she got her second Covid 19 vaccine, both tested positive for the Covid 19 virus. She was worse than he was and was not admitted to the hospital, she went to the hospital at the advice of her lung doctor to receive an infusion and was only at the hospital for 3 hours getting the infusion. At that point she had to wait 90 days to receive her second Covid 19 vaccine. If she had no symptoms, she would be able to get it. Her 90 day time frame was up yesterday, 05May2021 and she received her second Covid 19 vaccine yesterday. He reports the CDC and her lung doctor and primary care doctor all had different answers when it came to deciding when she could receive her second vaccine. Her doctors have said she still had the Covid 19 virus and had been treated with steroids and inhalers and had chest x-rays. She feels like she has a lot of weight on her chest and she was coughing constantly. There was some confusion if having to wait more than 42 days between Covid 19 vaccines will require a third vaccine. This report is not related to a study or programme. Investigation Assessment was reported as yes. Outcome was recovered for events cough, headache, sinus issues on 05Feb2021. Outcome was unknown for events drug ineffective, Covid-19, tiredness and weak.  Follow up attempts are needed, further information has been requested.