Sex: M
Vaccine: COVID19
Symptoms: Investigation, Lumbar puncture, Magnetic resonance imaging head, Neutrophil count, Protein total
Clinical narrative: COVID positivity was determined through PCR testing, and patient reported receival of two COVID mRNA vaccinations several months prior; COVID-19; This is a literature report for the following literature source(s):   A 70-year-old male patient received COVID-19 Vaccine - Manufacturer Unknown, as dose 1, single (Batch/Lot number: unknown) and as dose 2, single (Batch/Lot number: unknown) for covid-19 immunisation. The patient's relevant medical history included: "type 2 diabetes mellitus" (ongoing); "coronary artery disease" (unspecified if ongoing); "progressively worsening headache" (unspecified if ongoing); "hemiparesis" (unspecified if ongoing), notes: new right sided; "covid pneumonia" (unspecified if ongoing). The patient's concomitant medications were not reported. The following information was reported: DRUG INEFFECTIVE (hospitalization, medically significant), outcome "unknown", described as "COVID positivity was determined through PCR testing, and patient reported receival of two COVID mRNA vaccinations several months prior"; COVID-19 (hospitalization, medically significant), outcome "unknown". The patient underwent the following laboratory tests and procedures: Biopsy brain: pathology revealed, notes: a nonspecific reactive gliosis; Blood glucose: 66 mg/dl; Computerized tomogram head: revealed a new focal, notes: hypodensity in the posterior left frontal lobe; Computerized tomogram thorax: patchy consolidation and ground glass opacities in, notes: bilateral lungs without evidence of nodular lesions or cavitation consistent with multifocal pneumonia. He was also found a small right lower lobe pulmonary embolism; obtained to evaluate for possible, notes: Nocardia lung abscesses that revealed stable ground glass opacification of bilateral lungs without nodular or cavitary lesions; CSF culture: negative; Culture: Negative; revealed light growth, notes: Nocardia farcinica; Cytology: Negative; Imaging procedure: revealed extension, notes: of the cervical spine lesion from the skull base to C7 with peripheral enhancement and internal necrosis at C5 level; resulted in improvement in, notes: symptoms; Staining: revealed modified acid fast, notes: branching rods; Lumbar puncture: an opening pressure of 12 cm H2O, notes: [reference range 5-20 cm H2O], white blood cell count of 13/uL [reference range less than 5/uL] with 19 % neutrophils, glucose 66 mg/dL, protein 165 mg/dL, red blood cell count of 2/uL, and five oligoclonal bands; revealed resolution of the pleocytosis; Magnetic resonance imaging head: revealed scattered ring enhancing lesions with, notes: surrounding vasogenic edema along the grey-white junction as well as a large irregular lesion involving the proximal cervical spinal cord; stable from previous; showed resolution of, notes: ring enhancing lesions; Neutrophil count: 19 %; Protein total: 165 mg/dl; Red blood cell count: 2 /mm3; SARS-CoV-2 test: positivity; White blood cell count (normal high range 5): 13 /mm3. Therapeutic measures were taken as a result of covid-19. The following death information was reported, despite no fatal outcome. The patient date of death was unknown. Reported cause of death: "patient continued to clinically deteriorate despite supportive measures". It was not reported if an autopsy was performed.; Sender's Comments: Based on plausible dose -event relationship post vaccination and no other alternate explanation the causal role of BNT162B2 cannot be excluded for the reported LOE events.; Reported Cause(s) of Death: patient continued to clinically deteriorate despite supportive measures; patient continued to clinically deteriorate despite supportive measures.