Age: 72.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Asthenia, Blood test, Cluster headache, Computerised tomogram, Myalgia
Clinical narrative: brain fog; vestibular disorder; wasn't moving around so much; I have to use my hands to stand up from a sitting position , can't stand up without using arms; It hurt so bad; he is now bedridden; can't walk anymore; weakness in legs; leg muscle aches, muscle aches on my shoulders; headache came back, still experiences headache now, I know I still have a headache, 1-2 out of 10 on the pain scale; first dose was Pfizer, second dose was Moderna; vaccine threw me for a loop ,  Within 4 hours of getting a shot I don't know whether is cytokine or autoimmune; Within 4 hours of the Moderna shot, he had (and still has) long haul symptoms from it/ Everything hit all at once within 4 hours after getting the shot; severe sinus headache on the left side of his face / tremendous sinus headache; This spontaneous case was reported by a consumer and describes the occurrence of SINUS HEADACHE (severe sinus headache on the left side of his face / tremendous sinus headache), FEELING ABNORMAL (brain fog), VESTIBULAR DISORDER (vestibular disorder), HYPOKINESIA (wasn't moving around so much) and DYSSTASIA (I have to use my hands to stand up from a sitting position , can't stand up without using arms) in a 72-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch no. 033H21A) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below.     The patient's past medical history included Bypass surgery (patient had triple bypass heart surgery and he started physical therapy at that time.) on 14-Jul-2021 and Hip fracture (patient broke his left trochanter, which was a slight hip fracture.) in November 2021. Previously administered products included for COVID-19 vaccination: Pfizer (Dose number 1, Lot number : EW0182, Route: Intramuscular and location: right arm) on 20-May-2021. Past adverse reactions to the above products included No adverse event with Pfizer. Concurrent medical conditions included Bee sting, Ex-smoker and Ex-alcohol user. Concomitant products included CLOPIDOGREL HYDROCHLORIDE (CLOPIDOGREL [CLOPIDOGREL HYDROCHLORIDE]), MIRTAZAPINE, FAMOTIDINE, METOPROLOL TARTRATE, DIPHENHYDRAMINE HYDROCHLORIDE (BENADRYL N), ACETYLSALICYLIC ACID (BABY ASPIRIN), VITAMIN B12 NOS, COLECALCIFEROL (VITAMIN D3), IRON and VITAMINS NOS for an unknown indication.    On 05-Jan-2022, the patient received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 05-Jan-2022, the patient experienced POST VACCINATION SYNDROME (Within 4 hours of the Moderna shot, he had (and still has) long haul symptoms from it/ Everything hit all at once within 4 hours after getting the shot) and INTERCHANGE OF VACCINE PRODUCTS (first dose was Pfizer, second dose was Moderna). 05-Jan-2022, the patient experienced VACCINATION COMPLICATION (vaccine threw me for a loop ,  Within 4 hours of getting a shot I don't know whether is cytokine or autoimmune). On an unknown date, the patient experienced SINUS HEADACHE (severe sinus headache on the left side of his face / tremendous sinus headache). an unknown date, the patient experienced FEELING ABNORMAL (brain fog), VESTIBULAR DISORDER (vestibular disorder), HYPOKINESIA (wasn't moving around so much), DYSSTASIA (I have to use my hands to stand up from a sitting position , can't stand up without using arms), PAIN (It hurt so bad), MYALGIA (leg muscle aches, muscle aches on my shoulders), HEADACHE (headache came back, still experiences headache now, I know I still have a headache, 1-2 out of 10 on the pain scale), BEDRIDDEN (he is now bedridden), GAIT DISTURBANCE (can't walk anymore) and MUSCULAR WEAKNESS (weakness in legs). The patient was treated with PREDNISONE on 25-Jan-2022 for Headache, at a dose of 1 dosage form; DIPHENHYDRAMINE HYDROCHLORIDE (BENADRYL N) at a dose of 1 dosage form as required; AMOXICILLIN for Sinus headache, at a dose of 1 dosage form and Physical therapy for Vestibular disorder. At the time of the report, SINUS HEADACHE (severe sinus headache on the left side of his face / tremendous sinus headache) had resolved, FEELING ABNORMAL (brain fog), HYPOKINESIA (wasn't moving around so much), DYSSTASIA (I have to use my hands to stand up from a sitting position , can't stand up without using arms), PAIN (It hurt so bad), POST VACCINATION SYNDROME (Within 4 hours of the Moderna shot, he had (and still has) long haul symptoms from it/ Everything hit all at once within 4 hours after getting the shot), MYALGIA (leg muscle aches, muscle aches on my shoulders), HEADACHE (headache came back, still experiences headache now, I know I still have a headache, 1-2 out of 10 on the pain scale), BEDRIDDEN (he is now bedridden), GAIT DISTURBANCE (can't walk anymore), MUSCULAR WEAKNESS (weakness in legs) and VACCINATION COMPLICATION (vaccine threw me for a loop ,  Within 4 hours of getting a shot I don't know whether is cytokine or autoimmune) had not resolved, VESTIBULAR DISORDER (vestibular disorder) was resolving and INTERCHANGE OF VACCINE PRODUCTS (first dose was Pfizer, second dose was Moderna) outcome was unknown.            Patient did not get a second dose of Pfizer.   On an unknown date, patient went to the hospital. Patient consulted neurologist on 7Mar2022. Patient's general practitioner prescribed amoxicillin, but it did nothing. On 25Jan2022, patient took one prednisone, and after 2 hours, his pain went down to 2 on a pain scale. He took another one the next day because the headache came back. Again, it subsided down to 2 on a pain scale after a couple hours of taking the prednisone. He still experienced the headache at the time of this report. It was 1-2 out of 10 on the pain scale, however patient knew that he still had headache. Patient was hit badly and his autoimmune system was supercharged. Event of vestibular disorder improved because of physical therapy. Patient's doctor recommended a recovery program for long-term COVID at the hospital. Patient was on Benadryl off and on. After the shot, patient never got a fever, never lost sense of taste/smell, no heart palpitations.  It was further reported that within 4 hours of getting a shot, unknown if it was cytokine or autoimmune, a rare case which had been going on for over 90 days.   Most recent FOLLOW-UP information incorporated above includes: On 13-Apr-2022: Events and narrative updated. On 13-Apr-2022: Non Significant Follow-up appended