Age: 75.0
Sex: F
Vaccine: COVID19
Symptoms: Insomnia, Investigation, Oropharyngeal pain, Paraesthesia, Rash
Clinical narrative: rash on her scalp; flat macular rash; on her scalp the vesicles were breaking out basically; Pain in her throat one side, injection on the right side, just in the right peritonsillar fossa; very foggy; trouble sleeping; numbness; paresthesia; Shingles; Rash around her eye; Sore throat; Earache; This is a spontaneous report from a patient. A 75-year-old female patient received bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE), dose 2 via an unspecified route of administration, administered in Arm Left on 18Feb2021 (Batch/Lot Number: EN6201) as a single dose (at the age of 75 years) for covid-19 immunization. The patient's medical history included lung Cancer from Aug2010 to Oct2010 (lung cancer survivor and had 35 days of treatments, 20Sep2010 was her last day of treatment. She says the end date for this condition was mid Oct2010, she has inoperable lung scarring, it's not COPD, more like a seasonal allergy, when she runs into an URI they up the prednisone to stop the spasms. She clarifies that URI stands for upper respiratory infection; ongoing sleep obstructive sleep apnea (patient uses a CPAP. She says she has had this condition prior to 2010, since the early 2000's), polymyalgia rheumatica from 2019 and ongoing,ongoing hypothyroidism (had this condition for 30 years probably) , hypertension from Feb2021 and ongoing; gastrooesophageal reflux disease (since the 1990's), chemotherapy and radiation (chemotherapy and radiation 10 years ago), postmenopausal and inoperable lung scarring from an unknown date and unknown if ongoing. Concomitant medication included prednisone (PREDNISONE) taken for polymyalgia rheumatica from; budesonide, formoterol fumarate (SYMBICORT) taken for lung neoplasm malignant; salbutamol sulfate (ALBUTEROL [SALBUTAMOL SULFATE]) taken for lung neoplasm malignant; omeprazole (PROTONIX [OMEPRAZOLE]) taken for gastrooesophageal reflux disease; levothyroxine sodium (SYNTHROID) taken for hypothyroidism from an unspecified start date and ongoing; calcium carbonate, vitamin d nos (CALCIUM + VIT D) taken for postmenopause from an unspecified start date and ongoing; ascorbic acid (VIT C) taken for postmenopause; hydrochlorothiazide (HYDRODIURIL) taken for hypertension from Feb2021 to an unspecified stop date. The patient received the first dose of BNT162B2 (lot:EL9262) in the left arm on 21Jan2021 at the age of 75 years for Covid-19 immunization. The patient experienced shingles, rash around her eye, sore throat, earache on 29Mar2021; numbness, paresthesia and  trouble sleeping on 31Mar2021; very foggy on 03Apr2021; very foggy was reported as worsened/ trouble sleeping was reported as worsened, rash on her scalp, flat macular rash, on her scalp the vesicles were breaking out basically, pain in her throat one side, injection on the right side, just in the right peritonsillar fossa  on an unspecified date. It was further reported that 5 and a half weeks later (after the vaccine) she developed shingles. She said it just recently came to her attention and might be related to the vaccine, but she was not sure if it was or not. She said she has not had the shingles vaccine, she had chemotherapy and radiation 10 years ago and never had any issues so she never got the vaccine for shingles. Patient is on a dose of gabapentin 800mg for the shingles, she has had a lot of difficulty with the dose and the shingles, She said she was little bit fuzzy, but that's probably because of the gabapentin, not the vaccine. Patient also mentioned she had a sore throat, it involves the right forehead, scalp, neck, she has an earache. She said the earache and the sore throat have passed but she still has the issue around her eye, a rash. She said the numbness and paresthesia started, she didn't pay much attention to it, then 2 days later she thought she should see the doctor. She says she saw a rash on her scalp, she didn't see the vesicles right away, she saw a flat macular rash. She says on her scalp the vesicles were breaking out basically. She says the sore throat has been interfering with her sleep, she can't use her CPAP, it got to disabling because she can't use her CPAP. She was very foggy. Trouble sleeping was medically significant moving into disabling because she was really foggy, more foggy as she goes along. She says the foggy is medically significant moving towards disabling, that up until today it was medically significant. She said for her throat she had to gargle a lot, it didn't go away with Tylenol. Tylenol NDC, lot, and expiration date not provided. She says the earache was there, it was annoying. She said the trouble sleeping was related to the shingles, she can't say the vaccine did it. The patient underwent lab tests and procedures included bloodwork on 02Apr2021 and everything came back normal. She said that was to test her kidney function following the HydroDiuril. She said the HydroDiuril was changed from 25mg to 12.5mg. She says she also had a screen of her inflammation markers of her lungs and that that was normal. She says both tests were done on 02Apr2021, that was the last ones, not the first ones done.  The patient went to her doctor and ophthalmologist and was prescribed Valtrex. She does not know the dose and frequency, she says it is an antiviral for shingles. She says the gabapentin was for the pain for the paresthesia. The gabapentin was fluctuating, they keep increasing it due to discomfort, and she was up to 800mg in divided doses. She said she also was given eye drops, triple antibiotic polymixin. She had neomycin and another one, that it was the same as the ointment triple antibiotic for abrasions. She used that 3 times a day in her right eye. She also took a cortisone preparation eye drops and that they are also 3 times a day in her right eye. She says her ophthalmologist put her on a second course of Valtrex, she does not know the dose or frequency, saying that it varies according to her primary care physician. She says the total is 800 mg in divided doses. She says she is doing 200, 200, 400, she is trying to get off of it but that doesn't work so they are going to be increasing it. The organ involvement included respiratory and Dermatological/Mucosal. The patient was recovering from the events shingles and rash around her eye, recovered from sore throat, earache on 19Apr2021, not recovered from the events numbness, paresthesia, very foggy, trouble sleeping, and unknown outcome for all the other events.