Age: 57.0
Sex: F
Vaccine: COVID19
Symptoms: Bartonella test, Borrelia test, Cheilitis, Computerised tomogram, Epstein-Barr virus antibody
Clinical narrative: Ageusia, reduction in ability of taste; Myalgia muscle pain; Dysesthesia electric tongue; numbness of tongue; Raw skin, Lips, roof of mouth; Raw skin, Lips, roof of mouth; Raw skin, Lips, roof of mouth; Lyme disease IgG/IgM Abnormal: Pos (Index 1.46); Fatigue-whole body; Hypoesthesia palsy of head; ANA Homogenous Pattern; Hematocrit high (47.1%); MCH high (31.3 pg); Peripheral neuropathy numb hand; numb hand, neck shoulders; Blurred vision; This is a spontaneous report received from contactable reporter(s) (Consumer or other non HCP). The reporter is the patient.  A 57 year-old female patient received bnt162b2 (BNT162B2), intramuscular, administered in arm left, administration date 12Apr2021 13:45 (Lot number: EW0150) at the age of 57 years as dose 2, single for covid-19 immunisation. Relevant medical history included: "UTI" (ongoing); "Herpes" (unspecified if ongoing). Concomitant medication(s) included: ACYCLOVIR [ACICLOVIR] taken for herpes simplex (ongoing) and unspecified antibiotics for urinary tract infection (UTI). Prior vaccinations (within 4 weeks) were none. Vaccination history included: Bnt162b2 (Dose 1; Batch/Lot number: Pfizer En6207; Time: 13:45; Anatomical site of injection: left arm; Route of administration: Intramuscular), administration date: 22Mar2021, when the patient was 57 years old, for Covid-19 Immunization, reaction(s): "Whole body Paresthesia", "itching specially arms, legs", "Joint pain Arthralgia", "Migraine", "Cephalgia", "Cognitive Impairment Brain fog", "Neck and joint pain", "Presyncope Dizziness", "Presyncope Dizziness", "Swelling, Edema of fingers, ankles", "Swelling, Edema of fingers, ankles"; Bnt162b2 (Dose 1; Batch/Lot number: Pfizer En6207; Time: 13:45; Anatomical site of injection: left arm; Route of administration: Intramuscular), administration date: 27Mar2021, when the patient was 57 years old, for Covid-19 Immunization, reaction(s): "Insomnia"; Bnt162b2 (Dose 1; Batch/Lot number: Pfizer En6207; Time: 13:45; Anatomical site of injection: left arm; Route of administration: Intramuscular), administration date: 22Mar2021, when the patient was 57 years old, for COVID-19 Immunization, reaction(s): "Hypertension", "heart racing"; Bnt162b2 (Dose 1; Batch/Lot number: Pfizer En6207; Time: 13:45; Anatomical site of injection: left arm; Route of administration: Intramuscular), for Covid-19 Immunization, reaction(s): "Depression". The following information was reported: NEUROPATHY PERIPHERAL (disability, medically significant) with onset 01May2021, outcome "not recovered", described as "Peripheral neuropathy numb hand"; HYPOAESTHESIA (disability, medically significant) with onset 01May2021, outcome "not recovered", described as "numb hand, neck shoulders"; VISION BLURRED (disability) with onset 01May2021, outcome "recovering", described as "Blurred vision"; HYPOAESTHESIA (medically significant) with onset 27May2021, outcome "recovered" (28May2021), described as "Hypoesthesia palsy of head"; MYALGIA (disability) with onset 01Oct2021, outcome "not recovered", described as "Myalgia muscle pain"; ORAL DYSAESTHESIA (disability) with onset 01Jul2021, outcome "not recovered", described as "Dysesthesia electric tongue"; HYPOAESTHESIA ORAL (disability) with onset 01Jul2021, outcome "not recovered", described as "numbness of tongue"; SKIN EROSION (disability), CHEILITIS (disability), STOMATITIS (disability) all with onset 01Jul2021, outcome "not recovered" and all described as "Raw skin, Lips, roof of mouth"; FATIGUE (disability) with onset 01Jun2021, outcome "not recovered", described as "Fatigue-whole body"; AGEUSIA (medically significant), outcome "not recovered", described as "Ageusia, reduction in ability of taste"; LYME DISEASE (medically significant) with onset 11Jun2021, outcome "unknown", described as "Lyme disease IgG/IgM Abnormal: Pos (Index 1.46)"; ANTINUCLEAR ANTIBODY POSITIVE (non-serious) with onset 11May2021, outcome "unknown", described as "ANA Homogenous Pattern"; HAEMATOCRIT INCREASED (non-serious) with onset 11May2021, outcome "unknown", described as "Hematocrit high (47.1%)"; MEAN CELL HAEMOGLOBIN INCREASED (non-serious) with onset 11May2021, outcome "unknown", described as "MCH high (31.3 pg)". The events "peripheral neuropathy numb hand", "numb hand, neck shoulders", "blurred vision", "hypoesthesia palsy of head", "myalgia muscle pain", "dysesthesia electric tongue", "numbness of tongue", "raw skin, lips, roof of mouth", "raw skin, lips, roof of mouth", "raw skin, lips, roof of mouth" and "fatigue-whole body" were evaluated at the physician office visit (PCP visit, neurologist visit). The patient underwent the following laboratory tests and procedures: antinuclear antibody: (11May2021) positive high, notes: Units: 1:160; babesiosis: (11Jun2021) negative, notes: Babesia duncani Neg; bacterial test: (11Jun2021) negative, notes: Anaplasma phagocytophilia; bartonella test: (11Jun2021) igm neg (index 0.02), igg neg (index 0.63), notes: Bortonella henselae, Bortonella clarridgelae, Bortonella bacilliformis, Bortonella ellzabethae, Bortonella Quintana; borrelia test: (17Jun2021) igm result: negative (non-reactive); (11Jun2021) negative; computerised tomogram: (30May2021) unknown results; epstein-barr virus antibody: (11May2021) positive; (11Jun2021) igm neg (index 0.05) igg neg (index 1.34); haematocrit (37.0-47.0): (11May2021) 47.1 %; haemoglobin (12.5-18.0): (11May2021) 15.2 g/dl; human herpes virus 6 serology: (11Jun2021) igm neg; human herpes virus 8 test: (11Jun2021) negative; investigation: (11Jun2021) negative, notes: HHV 7; lyme disease: (11Jun2021) normal: neg (index 0.86), notes: C6 Peptide; (11Jun2021) abnormal: pos (index 1.46); (11Jun2021) negative, notes: IgMCDC Neg, IgMAlt Neg, IgGCDC Neg, IgGAlt Neg, Borrella afzelil Neg, Borrella garinll  Neg, Borrella lonestarl Neg, Borrella mlyamotol Neg, Borrella turlcatae  Neg, Borrella mayonll Neg; magnetic resonance imaging: (11Jun2021) ms not present; mean cell haemoglobin (27.0-31.0): (unspecified date) 31.3 pg; mean cell haemoglobin concentration (32.0-36.0): (11May2021) 32.3 g/dl; mean cell volume (78.0-100): (unspecified date) 96.6, notes: Units: fL; mean platelet volume (6.0-9.5): (11May2021) 8.7, notes: Units: fL; platelet count (150-450): (11May2021) 230, notes: Units: x10 (3)uL; red blood cell count (4.20-5.40): (11May2021) 4.66 10*6/uL; red cell distribution width (11.5-14.0): (11May2021) 12.0 %; typhus rickettsia test: (11Jun2021) negative; white blood cell count (4.0-10.5): (11May2021) 6.1, notes: Units: x10 (3)/uL. Therapeutic measures were taken as a result of neuropathy peripheral, hypoaesthesia, oral dysaesthesia, hypoaesthesia oral. Therapeutic measures were not taken as a result of vision blurred, hypoaesthesia, myalgia, skin erosion, cheilitis, stomatitis, fatigue, ageusia. It was reported that medications do not seem to help except for Nurtec.