Age: 64.0
Sex: F
Vaccine: COVID19
Symptoms: Antibody test, Antinuclear antibody positive, Arthralgia, Arthritis, Double stranded DNA antibody positive
Clinical narrative: ESR is slightly high at 40; arthritis inflammation in my hands and shoulders; daily hand swelling; shoulder joint stiffness; frozen shoulder diagnosis; rheumatoid arthritis flare up; shoulder pain; This is a spontaneous report from a contactable consumer (patient). A 64-year-old female patient received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, solution for injection), dose 2 intramuscular, administered in arm right (upper) on 15Mar2021 13:00 (Batch/Lot Number: EL6207) (at the age of 64-years-old) as DOSE 2, SINGLE for COVID-19 immunisation.  Medical history included autoimmune disorder, sjogren's syndrome from 2017 and ongoing (dry mouth/ flare per year(3-5days)), also patient's sister, brother and sister's daughter (50years old) have this autoimmune syndrome; high blood pressure, thyroid disorder, hypothyroidism from 2014 and ongoing (blood work results); reflux from 2014 and ongoing; arthritis knee from 2014 to 2020, she had bilateral knee replacement in 2019/2020, allergy to sulfa antibiotics, dry mouth, and hand joint inflammation. Concomitant medications included levothyroxine sodium (SYNTHROID); acebutolol (ACEBUTOLOL) and linaclotide (LINZESS). The patient's father had psoriatic arthritis. Historical vaccine included BNT162B2 dose 1 intramuscular, administered in the right upper arm on 18Feb2021 13:00 (lot number: EL9266) (at the age of 64-year-old) for COVID-19 immunization with no side effects. The patient was not pregnant. The patient did not receive any other vaccine within 4 weeks prior to the COVID vaccine. The patient was not diagnosed with COVID-19 prior to vaccination. She had not been tested for COVID-19 since the vaccination. Prior vaccinations were none. It was reported that the patient had a known autoimmune disease (Sjogrens). One week after receiving her second dose, she started to have arthritis inflammation in her hands and shoulders. She was still am experiencing this 3 months later. She did not have this after the first dose. The patient was diagnosed with Sjogren's Syndrome several years ago but experienced only an occasional dry mouth and hand joint inflammation which occurred just 1x-2x a year (lasting a few days) with nothing recent leading up to her 2nd covid vaccine. She had no side effects from the first vaccine on 18Feb2021. However, two weeks after her 2nd shot on 15Mar2021, she developed daily hand swelling and shoulder joint stiffness which resulted in a frozen shoulder diagnosis. She visited her primary care doctor who ordered an auto immune lab panel. She mentioned that many of her results were abnormal and in the "high level" range which indicated (per her doctor) that she was in a flare situation, a rheumatoid arthritis flare up. She was instructed to follow-up with my rheumatologist which she did. Her doctor suggested that she try anti-inflammatory medications (which she cannot take due to stomach reasons). Her most recent visit was with her orthopedic physician who gave her a cortisone injection into her shoulder which gave her relief from the hand swelling and shoulder pain so far. She had been suffering with these symptoms since 29Mar2021, two weeks post 2nd vaccine injection. She confirmed that the second vaccine was the only thing different she had done since this whole ordeal began. She was thinking that her auto immune "flare" had quite a bit to do with the second vaccine dose she received. She commented that her limited rheumatology knowledge had led her to believe that the 2nd shot set her already overactive immune system into an overdrive. She added that her family relations, who also suffered with auto immune disorders are also experiencing issues. Especially her 50-year-old niece who had been battling bilateral wrist pain and swelling since her 2nd shot. She spoke with her the other day, and learned she was having similar symptoms. She suffers from Sjogren's and Lupus. The patient underwent lab tests and procedures which included ANA reflux to IFA with positive result (NEG=<1:80, abnormal, Status: Final, ANA screen ethodology: semiquantative indirect fluorescent antibody) on 29Apr2021; Anti SM was 21.8 (<20.0, Units: CU, high. Status: Final) on 29Apr2021; Anti SSA was 104.0 (<20.0, Units: CU, HIGH, Status: Final Report: ANTI-R060) on 29Apr2021; Anti -DSDNA was 72.9 IU/ml (Ref. range <27.0, high, Status: Final) on 29Apr2021; SED rate was 40 (Ref. range: 0-29, Units: mm/hr, High, Status: Final) on 21Apr2021; and ANA TITER was 1.640 (<1.80 (titer), high, Status: Final, ANA pattern-homogenous cytoplasmic staining seen) on 29Apr2021. Her ESR was slightly high at 40 on an unspecified date with unknown outcome. Therapeutic measures were taken as a result of the events. The events (except 'ESR was slightly high at 40') started on 29Mar2021 which are ongoing. The events are reported serious per significant disability with outcome of not recovered. The events resulted to physician office visit.