Age: 89.0
Sex: M
Vaccine: COVID19
Symptoms: Biopsy kidney, Dyspnoea, Fatigue, Glomerulonephritis membranous, Muscle spasms
Clinical narrative: stage three kidney failure; biopsy report included membraneous glomerulopathy; leg muscle pain; swelling in his legs; tired; shortness of breath; Severe cramps in legs, arms, hands.; This is a spontaneous report from a contactable consumer (patient). An 89-year-old male patient received bnt162b2 (Comirnaty, solution for injection; Lot Number: EL9264; NDC and expiry date: unknown), dose 2 via an unspecified route of administration, administered in left arm on 10Mar2021 at 15:30 (at the age of 89-year-old) as dose 2, single for COVID-19 immunization. Medical history included heart attack (from 5 or 6 years ago; had last heart attack at Thanksgiving, unsure of the date) and stated he had several heart attacks and several strokes but he is unsure of the dates; stroke; ongoing asthma and allergies from an unknown date. Patient historical vaccine included first dose bnt162b2 (solution for injection) at on 10Feb2021 at 15:30 PM (at the age of 89 years) in left arm for covid-19 immunisation. Concomitant medication included albuterol [salbutamol] takes off and on a puff a day; allopurinol taken for gout at 100 mg, once daily by mouth oral route; aspirin [acetylsalicylic acid] at 325 mg, once daily by mouth, orally to keep the blood thin; azelastine taken for asthma and allergy; 0.1 mg take two spray in the evening to the nostrils via nasal spray; clopidogrel orally at 75 mg, once a day (once daily by mouth) taken for heart; fluticasone via nasal route at 50 mg, daily two sprays by nostril daily for allergic asthma; levothyroxine sodium orally at 75 ug, once daily by mouth; metoprolol tartrate via oral route at 25 mg, once daily by mouth; rosuvastatin taken orally 200 mg, once daily by mouth; spironolactone taken orally 25 mg, once daily by mouth; tizanidine orally at 4 mg, once daily by mouth; calcium carbonate/ colecalciferol (VITAMIN D 2000); fluticasone propionate/ salmeterol xinafoate (WIXELA INHUB) once daily; fish oil orally at 100 mg, twice a day (1000 twice daily by mouth) prescribed by cardiologist; losartan at 25 mg might be one he has not taken; multivitamins (vitamins NOS) once a day; thinks this is for reflux and he stopped it for some reason. Patient had received first and second dose of the Pfizer BioNTech Covid 19 vaccine on 10Feb2021 and 10Mar2021. Subsequent to that he developed leg muscle pain, swelling in his legs, shortness of breath, and being really tired on an unknown date in 2021, the exact timeliness was unknown. He saw the cardiologist to rule out heart issues. DSU agent said he was diagnosed with kidney cancer, but patient then clarified he had stage three kidney failure on an unknown date.  He has a past medical history of stroke.  His biopsy came back this week and started seeing the nephrologist a month or two ago.  His biopsy report included membraneous glomerulopathy, NELL+ L1, antigen is one-third NELL+, working to see underlying malignancy is warranted, sclerosis 5, intestinal fibrosis mild, focal segmental glomerulosclerosis absent, and anterior hilalnosi mild.  His son is a physician and an associate vice chancellor of medication and research. His son told him to call to see if there are any cases or reports of this and what was used to treat it. Patient went to physician office visit to the cardiologist for the shortness of breath. Prior to vaccination, the patient was not diagnosed with COVID-19; and since the vaccination, has not been tested for COVID-19. The patient did not receive any other vaccines within 4 weeks prior to the COVID vaccine. Patient stated the reason for calling was he had been diagnosed with stage three kidney failure and as far as he can go back a lot of it started after getting one of the Pfizer Vaccine shots. He had all kinds of tests including a biopsy of the kidney and would like to let Pfizer know he has a certain type of kidney disease and would like to know if Pfizer has any research or if anyone else has reported this? Product: Pfizer COVID 19 vaccine; treatment first dose reported as 12Feb2021 but corrected to 10Feb2021 at 15:30PM in the left arm; lot ES1686 or EJ1686; second dose reported as possibly 12Mar2021 or 13Mar2021 then corrected to 10Mar2021 at 15: 30PM in the left arm; lot EL9264. Patient stated as far as he can recall he believes this all started after he got the COVID vaccination. Caller reported he just got the biopsy results in the last two weeks but he first noticed swelling in his legs that was odd. He unsure of whether is was after the first or second dose or exactly when he noticed it but that all this stuff happened after the vaccination. Adds he put up with that without doing anything until he started to get other symptoms. Next he noticed shortness of and felt really tired. Adds recently he has had severe cramps in his legs, arms, hands. Reports his legs are still swelling up though slightly improved; he has not had the shortness of breath for a month and a half; but he is still really tired, sometimes he has to find a chair to sit-down because it comes on suddenly after climbing up steps or just walking to the kitchen. The patient underwent lab tests which included kidney biopsy which showed with stage three kidney failure on an unknown date and his biopsy report included membraneous glomerulopathy, NELL+ L1, antigen is one-third NELL+, working to see underlying malignancy is warranted, sclerosis 5, intestinal fibrosis mild, focal segmental glomerulosclerosis absent, and anterior hilalnosi mild. Unclear if the biopsy showed cancer or confirmed his kidney failure. Adds he has a blood test every month. After the first month there was a decline in his protein, and he was glad to hear that. Therapeutic measures were taken as a result of stage three kidney failure and shortness of breath. When he got the shortness of breath, he saw the cardiologist who did a month of workups and said his heart was certainly alright and recommended he see a nephrologist. He saw the nephrologist after a month or two and has been working with him for a couple of months. He thinks it was Jun2021 or Jul2021 when he saw the nephrologist and got his diagnosis of stage three kidney failure. Mentions he is on some medications now and that is where he is. States he is on three water pills a day to get rid of the doses of liquid. and his legs still swell up. Reports about a month after the reports to his kidney, the nephrologist started him on Tacrolimus 1 mg twice daily by mouth; caller cannot recall the water pills and thinks maybe the Levothyroxine was also started recently. The outcome of the events fatigue and dysphonea was recovering; muscle spasm was not recovered and Swelling of legs, leg pain and kidney failure was unknown.  Follow up attempts are completed. No further information is expected.