Age: 86.0
Sex: M
Vaccine: COVID19
Symptoms: Blood test, Epistaxis, Magnetic resonance imaging head, Red blood cell count decreased
Clinical narrative: low red blood cells; Bleeding from his nose; This is a spontaneous report from a contactable (patient's daughter). An 86-year-old male patient received bnt162b2 (PFIZER-BIONTECH COVID-19 mRNA VACCINE, Formulation: Solution for injection, Batch/Lot number was not reported), second dose via an unspecified route of administration, administered in left arm on 02Mar2021 at 13:00 (at the age of 86-year-old) as a single for COVID-19 immunisation. Medical history included diabetes mellitus from 2012 and ongoing Verbatim: Diabetes, ongoing hypertension Verbatim: Blood pressure high, hypersensitivity from an unknown date and unknown if ongoing Verbatim: Allergy, atrial fibrillation from 2009 to an unknown date Verbatim: Atrial fibrillation, blood cholesterol increased from an unknown date and unknown if ongoing Verbatim: High cholesterol, prophylaxis from an unknown date and unknown if ongoing, seasonal allergy from an unknown date and unknown if ongoing. Concomitant medications included rivaroxaban (RIVAROXABAN) taken for prophylaxis, start and stop date were not reported; metformin (METFORMIN) taken for diabetes mellitus, start and stop date were not reported; lovastatin (LOVASTATIN) taken for hypertension, start and stop date were not reported; cetirizine hydrochloride (ZYRTEC [CETIRIZINE HYDROCHLORIDE]) taken for seasonal allergy, start and stop date were not reported. Historical vaccine given to patient previously bnt162b2 (PFIZER-BIONTECH COVID-19 mRNA VACCINE, Formulation: Solution for injection, Batch/Lot number was not reported), first dose via an unspecified route of administration, administered in left arm on 09Feb2021 at 14:00 (at the age of 86-year-old) as a single for COVID-19 immunisation. The patient did not receive any other vaccines within 4 weeks prior to the COVID vaccine. No vaccine administered at military facility. No additional vaccines administered on same date of the pfizer suspect. On 03Mar2021, the patient experienced bleeding from his nose, On 05Mar2021, low red blood cells. It was reported that consumer stated her dad was fine with his first vaccine but after his second vaccine, her dad started having nose bleeds. Consumer stated her dad received his first Pfizer vaccine on 09Feb2021 and his second Pfizer vaccine on 02Mar2021. While obtaining patient details caller stated she is not sure of her dad's weight. Consumer stated on day 2, clarified as 03Mar2021, after her dad received his second vaccine, he started bleeding from his nose a lot, on the left side of his nose. There were consecutive days where her father was bleeding a lot, the blood was all over his clothing. The nose bleeds were heavy and strong from 03Mar2021 to 05Mar2021. Those three days the bleeding was horrible. On 05Mar2021, the nosebleed was so strong and heavy, she took her dad to the emergency room. Caller stated her dad was in the emergency room for 8 to 9 hours and then discharged home. Caller checked with dad's doctor, (name withheld) who instructed him to stop his blood thinner for 3 days, the medication to prevent strokes. The bleeding has not stopped. She clarifies her dad does still have nose bleeds but not as much or as heavy. Consumer says it's been 3-4 weeks and she was wondering and had concerns about his bleeding. Consumer asked if anyone else has reported nose bleeds. Concomitant products: When probed for the name of the blood thinner, she mentions her father is not given the brand Xarelto, it was the generic, Rivaroxaban. Consumer states before it was Coumadin and then the name was changed. Caller confirms her father takes a cholesterol medication, but she does not know which one because they keep changing the medication. Her father has seasonal allergies and takes an allergy medication. She clarifies her father takes Zyrtec sometimes, but sometimes they change the name. Sometimes, it's like a spray in his nose. Recently, when her father went to the doctor, he was prescribed an allergy medication that was a pill, but she can't remember the name of it. Her father told her the medication made him drowsy/sleepy so after 3 days he stopped it. Caller confirms he is not using the nasal spray because of the bleeding from his nose. Consumer was probed for Lot/expiry dates for the concomitant products listed, but this information was not known by the caller. Treatment: He was instructed by his primary physician, PRIVACY to use Vaseline for his nose to help stop the bleeding. Also, cold water or ice on his head has helped a lot. Investigations: Consumer stated dad had a blood test and an MRI of the brain while in the emergency room. Caller stated the MRI of the brain was normal. Caller stated the blood test showed no anaemia but low red blood cells, she stated probably for the nose bleeds. Adverse event required a visit to Emergency Room. Consumer stated her dad was in the emergency room for 8-9 hours and then discharged home. Adverse event required a visit to physician office. Therapeutic measures were taken as a result of bleeding from his nose (epistaxis). The patient underwent lab tests and procedures which included blood test: red blood count was low on Red blood count was low, magnetic resonance imaging head: normal on Normal. The outcome of the event bleeding from his nose was resolving and outcome of the other event was unknown.  No follow-up attempts are possible; information about lot/batch number cannot be obtained.