Age: 66.0
Sex: M
Vaccine: COVID19
Symptoms: Giant cell arteritis, Headache, Horner's syndrome, Magnetic resonance imaging, Muscle spasms
Clinical narrative: Horner's syndrome; tired; cataract surgery in right eye; Giant cell arteritis; Headache; burning sensation in left eye; sleep apnea; lower back was killing him; buckled over with cramps; This is a spontaneous report received from contactable reporter(s) (Consumer or other non HCP). The reporter is the patient.  A 66-year-old male patient received BNT162b2 (BNT162B2), on 24Mar2021 as dose 2, single (Lot number: EN6208) at the age of 66 years for covid-19 immunisation. The patient's relevant medical history included: "rotator cuff surgery", start date: 2003 (unspecified if ongoing); "Depression" (unspecified if ongoing). Concomitant medication(s) included: LORAZEPAM oral taken for depression (ongoing); MIRTAZAPINE taken for depression. Vaccination history included: BNT162b2 (Dose 1, Lot number: EL9269), administration date: 03Mar2021, for COVID-19 immunization. The following information was reported: MUSCLE SPASMS (hospitalization) with onset 24Mar2021, outcome "recovered" (24Mar2021), described as "buckled over with cramps"; BACK PAIN (hospitalization) with onset 25Mar2021, outcome "not recovered", described as "lower back was killing him"; SLEEP APNOEA SYNDROME (hospitalization) with onset 25Mar2021, outcome "not recovered", described as "sleep apnea"; EYE IRRITATION (hospitalization) with onset 26Mar2021, outcome "not recovered", described as "burning sensation in left eye"; HEADACHE (hospitalization) with onset 15Jun2021, outcome "recovered with sequelae" (Jul2021); GIANT CELL ARTERITIS (hospitalization) with onset Jul2021, outcome "not recovered"; CATARACT (hospitalization, medically significant) with onset 2022, outcome "unknown", described as "cataract surgery in right eye"; HORNER'S SYNDROME (hospitalization, medically significant), outcome "not recovered"; FATIGUE (hospitalization), outcome "not recovered", described as "tired". The events "horner's syndrome", "cataract surgery in right eye", "buckled over with cramps", "sleep apnea", "burning sensation in left eye", "headache", "tired" and "lower back was killing him" required emergency room visit. The patient underwent the following laboratory tests and procedures: Computerised tomogram: Unknown results, notes: 7 CT scans; Magnetic resonance imaging: Unknown results, notes: Had 14 MRIs. Therapeutic measures were taken as a result of cataract, sleep apnoea syndrome, eye irritation, headache, giant cell arteritis. Clinical course included: Clarified his first dose was given on 03Mar2021 and had a LOT of EL9269. Clarified he received the second dose in March not in May. Had an adverse effect from the vaccine. Had the vaccine on 03Mar2021 and the second dose on 24Mar2021.  After receiving the second dose he waited 15 minutes, and was let go. Was driving home and buckled over with cramps. Got home and was probably in men's room for a good hour and a half buckled over. Then he just laid down and fell asleep, woke up the next day and his lower back was killing him. Could hardly walk, bent over, shoulders hunched over and achy like he never felt before. Had rotator cuff surgery, lots of surgeries. Then it subsided. Next day he was driving to his sisters and started getting a burning sensation in his left eye. In the lower left eye, almost like he got suntan lotion in his eye. Got to his sisters, couldn't stay long, his eye was hurting him too much, sun was really bothering him. Next day woke up and it wasn't that bad, as the days go on now into Jun2021 and the eye was still bothering him.  Doesn't want to open up in the morning and is still like that. Has to put drops in his eyes to open it up. After that got on a flight and [City name withheld]. Never had a headache in his life, except for self induced from after too much wine. [City name withheld] and was at his friends house, woke up at 3am and felt like someone was shoving a pipe in his head, did not stop for 4 days. Couldn't take it anymore. Went to an Urgent Care and thought it was his sinuses or a change in weather. Flew back home, went to his doctor and started scrambling to neurologist and eye specialist. HCPs came up with that he had contracted some rare disease called giant cell arteritis. Had to take a vein out of his left temple and diagnosed it as giant cell arteritis. Had to put drops in his eye this morning. Had to have cataract surgery. Not getting better. Now diagnosed with another rare disease called Horner's syndrome and kept getting worse. Always tired, can't even function or change a lightbulb. Has been in and out of the hospital 6 times since he had the shot.  Knows it was the vaccine.  Before taking the shot was healthy 66 year old man who worked out 4 days a week. Hasn't been to the gym since he got the shot. His life is ruined and he doesn't know what to do. Had cataract surgery and never had problems with his eye. Clarified he had cataract surgery in one eye. Buckled over with cramps: Lasted a couple of hours. Went and laid down for the night. Laid on the couch and went to bed, woke up the next day and that is when his back was bad. Clarified the cramps ended 24Mar2021. Lower back was killing him: Comes and goes. Doesn't know how he will feel hour to hour.  Woke up felt good then stood up and is staggering now. Never staggered before.   Clarified the rotator cuff surgery was in 2003 before receiving the vaccine. Burning sensation in left eye: Doesn't burn anymore but doesn't open all the way. Has to put in medicine in it and it opens it up. headache: Stopped because he was put on 60mg of prednisone. HCP did a surgery on his eye. Clarified the surgery was on his temple and had a vein taken out. Diagnosed with giant cell arteritis. Headache stopped almost immediately after surgery. Every once in a while it comes in and leaves, comes and goes and reminds him it is still there.   Giant Cell Arteritis: Diagnosed around 10July2021 or 12Jul2021. Already on the prednisone which was taking care of those headaches. Was on 60mg for several months and is still on it now. Clarified is on 10mg now. The prednisone ate his skin all up. His leg, his arms. Continuously eating his skin. If he touched himself on anything he would bruise and bleed. Couldn't even have dog sit on his lap because he would bruise and bleed.  Couldn't shower for weeks. Had to go to wound center for treatment.  Prednisone is a good drug but it ate him up.  Prednisone: In a pharmacy bottle. Manufacturer: Formulation: Tablet, Dose: 60mg. With giant cell arteritis he can go blind. His eye sight isn't that good. Had to have cataract surgery in his right eye. Just had that and has to get glasses now. Hard for him to see. Doesn't have the headaches or jaw pain which are characteristic of giant cell arteritis.  Cataract surgery in right eye: Done 2 and a half months ago. Horner's Syndrome: Pupils dilate different on each side. Diagnosed: Same time as cataract surgery within the week. Clarified he was diagnosed with Horner's Syndrome before cataract surgery. It is hard for him to look up right now. Sitting outside on the stoop and to look at the sky it hurts him and he has to wear sunglasses a lot. Eyes burning and watering. Tired: Start Date: It has been so long he can't remember.  Hasn't done anything in months but go to the doctor's.  Has not done anything since. Only stays home, his social life is going to doctor's.  Went to the Pulmonologist, had sleep study, since his HCP was thinking he had sleep apnea.  He does have sleep apnea and is on a machine now.  That helps him, seems to help, but he doesn't have energy, has awakeness but no energy. Was a physical person who always worked with his hands and can't even do anything at his house anymore. Not getting better, getting worse. Like he actually feels like he is dying. Testing: Been in the hospital 5 or 6 times. Had 14 MRIs, 7 CT scans.  In the hospital: 3 times he was emergency room and 3 times he was admitted. Dates of hospital admissions unknown. Clarified he does not have specific test results to provide. Is going for another one for his neck.