Age: 71.0
Sex: F
Vaccine: COVID19
Symptoms: Fatigue, Influenza like illness, Myalgia, Pruritus, Rash
Clinical narrative: My wife is being tested for Dermatomyositis; muscle soreness; rash itched; Fatigue; rheumatoid arthritis; hair loss; rash is coveringhis wife's body (left to right and top top bottom, from knees going all the way up to the forehead) and described as half rash, half red and looks like a sunburn, bright red; some kind of flu or cold; This is a spontaneous report received from contactable reporter(s) (Consumer or other non HCP) from medical information team, Program ID:.  A 73-year-old female patient received BNT162b2 (BNT162B2), on 12Feb2021 as dose 1, single (Lot number: EN6201) at the age of 71 years, in arm, on 07Mar2021 as dose 2, single (Lot number: EN6206), in left arm, as dose 3 (booster), single (Batch/Lot number: unknown) and as dose 4 (booster), single (Batch/Lot number: unknown) for covid-19 immunisation. The patient's relevant medical history included: "IBD", start date: 2020 (ongoing), notes: IBD Caller states this is irritable bowel that she had before her Pfizer COVID-19 shots. The patient's concomitant medications were not reported. Vaccination history included: Pneumonia, for immunization. The following information was reported: RASH (non-serious) with onset Jun2021, outcome "not recovered", described as "rash is coveringhis wife's body (left to right and top top bottom, from knees going all the way up to the forehead) and described as half rash, half red and looks like a sunburn, bright red"; INFLUENZA LIKE ILLNESS (non-serious) with onset Jun2021, outcome "unknown", described as "some kind of flu or cold"; ALOPECIA (non-serious) with onset Sep2021, outcome "unknown", described as "hair loss"; RHEUMATOID ARTHRITIS (medically significant) with onset Mar2022, outcome "unknown"; DERMATOMYOSITIS (medically significant), outcome "unknown", described as "My wife is being tested for Dermatomyositis"; MYALGIA (non-serious), outcome "not recovered", described as "muscle soreness"; PRURITUS (non-serious), outcome "unknown", described as "rash itched"; FATIGUE (non-serious), outcome "not recovered". The event "rheumatoid arthritis" required physician office visit. The patient underwent the following laboratory tests and procedures: Biopsy: (unspecified date) Unknown results; Biopsy skin: (Apr2022) Unknown results; Blood test: (unspecified date) Unknown results; Weight: (unspecified date) 150 pounds. Therapeutic measures were taken as a result of rash, pruritus which include prednisone, influenza like illness which included Declomycin.  Clinical course: Reported as, reporters wife (patient) and her mother (73 and 91 years old, respectively) were experiencing the same rash. Patient being tested for Dermatomyositis or anything else that the blood tests and biopsies will find. Requestor also added that the rash was covering probably 30% to 40% of his wife's body ("left to right and top top bottom, from knees going all the way up to the forehead") and described as "half rash, half red" and "looks like a sunburn, bright red".The doctor wanted to test patient for cancer and anything else that might pop up. Caller states his wife(patient) just turned 73 years old in so she was 72 years old when the rash started and states his wife won't tell him her weight but he suspects she was 150 pounds. He states back in Jun2021, his wife had some kind of flu or cold and was prescribed something called Declomycin. His wife(patient) was given this medicine and immediately after her face flared up and his wife looked into the medicine and found that this medicine can cause sensitivity to the sun. Reporter states he and his wife got the first 2 Pfizer COVID-19 vaccines in earlier in the year. Reporter states later in summer his wife went to a dermatologist and the dermatologist pointed out that the medicine will cause that and should go away within a year. Reporter states in the meantime his wife's face was bright red and on her chest and arms. Reporter states his wife is also starting to lose her hair. Reporter states various expensive creams were prescribed and also the rash itched. Reporter states fast forward to Jan2022 or Feb2022, his wife starting to experience muscle problems. Reporter states the rash is not receding but the redness is. He states his wife's facial redness especially is still there but not bright red. He states in Jan2022 or Feb2022, his wife started to experience muscle issues. Reporter described the muscle issues as the type of getting up from a chair and her muscles don't react or her legs are not reacting. Reporter states to get out of a normal chair height his wife has to rock her trunk of her body 3-4 times before she can stand up. Reporter states his wife can't be pulled up as this causes pain but she needs support to test her muscles or warm up her muscles. He states his wife takes a minute to a minute and a half to get up from a chair to test her legs then her knees hurts and she has to stand a moment for 15-20 seconds before moving forward or walking. He states steps require a lot of effort for his wife and she is in various amounts of pain throughout the day. Caller states then in Mar2022 his wife went to her primary healthcare provider who thought she had rheumatoid arthritis and was to a rheumatoid arthritis doctor who decided to do a skin biopsy and take 14 vials of blood for blood tests. Reporter states so far the doctor has ruled out not cancer but before he prescribes prednisone for the rash as he believes that would be the right prescription. He states his wife has a muscle biopsy scheduled this week. The rash spread from below his wife's(patient) chin to across her chest and to her arms, hands, and upper legs. Reporter states he thinks the rash is stable as the rash is not worsening or getting better but has leveled off. Reporter states as a nurse looking at her would know this is a rash but other people may think leprosy or something worse. Muscle Soreness: Reporter states the muscle soreness started in Jan2022 or Feb2022, the muscle soreness is getting slightly worse but is not so debilitating that his wife can't get out of bed. Reporter states she needs baby steps to get something done muscularly. fatigue started in Feb2022 or Mar2022 and fatigue persists but is not getting worse. Reporter states his wife(patient) has received the first 2 COVID-19 vaccines and 2 booster doses of the COVID-19 vaccines. Reporter states he has when she got the first 2 COVID-19 vaccines but not her booster doses as his wife has those with her. Reporter confirms all 4 doses of the COVID-19 vaccines were from Pfizer. he does not have the dose or route of administration just the information given on the card. Reporter states his wife received the COVID-19 Vaccines in her arm. Pfizer COVID-19 Vaccine 3rd and 4th dose information is unknown. Reporter states she received the 3rd and 4th dose in January or February or early March of 2022. Patient had a lot of blood work done with 14 vials of blood. Reporter states his wife's (patient) skin biopsy results are in and patient is now waiting for a muscle biopsy. He states his wife is supposed to have her stitches out this week so she had the skin biopsy 2 weeks ago or middle of Apr2022. Caller states he and his wife have had all kinds of other vaccines like flu and pneumonia and one for being around babies but this was in the past more like 2020. Reporter states his wife was 71 years old at the time of her 1st and 2nd dose of the COVID-19 Vaccine and was 72 years old at time of 3rd and 4th booster dose of COVID-19 vaccine and his wife is now 73 years old. in Nov2021, patient received the Flu Shot. Reporter states following that Flu vaccine his wife's (patient) symptoms did not go away or increase.   The information on the batch/lot number for BNT162b2 has been requested and will be submitted if and when received.