Age: 86.0
Sex: M
Vaccine: COVID19
Symptoms: Erythema, Muscular weakness, Myalgia, Pain in extremity, Pruritus
Clinical narrative: purple, reddish color; hurt in the muscles; redness; There was no strength in the upper arm; between his shoulder and elbow there was slight swelling; Rash on right arm; Itch on the upper half of his right arm; his left arm between elbow and shoulder that started hurting; This is a spontaneous report from a contactable consumer (patient himself). A 86-years-old male patient received second dose of bnt162b2 (Pfizer BioNtech COVID vaccine, Solution injection; Batch/Lot Number: EN6199), intramuscular, administered in Arm Right on 08Mar2021 (at the age of 86-years-old) at 08:00 as single dose for covid-19 immunisation. Patient previously received first dose of bnt162b2 (Pfizer BioNtech COVID vaccine, Solution injection; Batch/Lot Number: EN6200; expiration date: unknown), intramuscular, administered in Arm Right on 15Feb2021 at 7:45 as single dose for covid-19 immunisation and had no adverse events. Medical history included that he is not diabetic but is on diabetic medication since age 65 as a precaution. He tested blood sugar and said he is on the borderline. What doses he was put on then, he is still on the same dose. Patient family medical history was none. On 10Mar2021, after 48 hours of vaccination, he started having symptoms on opposite arm that he received injection on. It was his left arm between elbow and shoulder that started hurting. He read the literature and it said you may have muscle pain. It was not so much muscle pain, but he could not lift or move arm without help of right hand. It was confined only to above the elbow to just below shoulder. Then 4-5 days later, he started feeling itching on the upper half of his right arm. So, when he took his shirt off and looked in the mirror, it started below injection site and went just above the elbow. Only one-half side of arm, the back side, was affected. It was not on the front, but on the backside where he could only see it in the mirror. It was a large area. It was purple, reddish color and itchy. It was the color of a rash and was very itchy. He wanted to know if someone else experienced this. On his left arm, he used Voltaren gel and it helps the muscle. On the right arm, he put Sensodyne cream on there. Both of them helped. His arm pain improved because he has been massaging with right arm and is pulling it up and down and used Voltaren Gel. He said it is very good for muscle pain. It used to be prescription. Now it is over the counter. That helped. He had to take shirt off to find it was itching and red. Right side was the side where he got injection. But where injection took place, the redness was below that and above elbow. It was only on one side, the back side. He can see it only in the mirror. Yesterday and the last 3 days, he has been putting cream on it, and was getting relief. The color was the same. The first injection was given on the left shoulder and he experienced no side effects. The second, two weeks apart, he asked them to put in his right shoulder. That did two things, within two or three days the left side between his elbow and shoulder of arm started hurting, was not swollen, but there was hurt in the muscles. For several days, he had to use his right hand to grab his left hand if he wanted to pull it up. There was no strength in the upper arm, he had to pull it up. On the right side, between his shoulder and elbow there was slight swelling but primarily redness that was very itchy. He started putting voltaren gel on his left side, which was best helping with pain. He also put Sensodyne cream against itch on his right side. After two weeks, itch is not gone. The redness is not gone but is almost completely disappeared. He thinks in a few days, it will be gone. His left arm is no different. He does not need the right arm to pull it up anymore, he can help pull it up but there is pain. Caller wants to know what to do if he has permanent damage or if something can be done, because it has to be caused by the coronavirus. The outcome of between his shoulder and elbow there was slight swelling was unknown while the outcome of all the other events was recovering  No follow-up attempts are possible. No further information is expected.