Age: 57.0
Sex: M
Vaccine: COVID19
Symptoms: Rheumatoid factor, Urine analysis
Clinical narrative: Headache; Shortness of breath; heart palpitation; joint pain mostly in his shoulder, hips, and knees; muscle pain, mostly in legs below the knees; This is a spontaneous report from a contactable physician, the patient. A 57-years-old male patient received bnt162b2 (PFIZER-BIONTECH COVID-19 mRNA VACCINE, solution for injection, lot number: 30130BA), via an unspecified route of administration, administered in Deltoid Left on 17Sep2021 at 12:15 as dose 1, single (at the age of 57-years-old) for covid-19 immunization. Medical history included ongoing controlled hypertension. It was reported that patient had inhalers as he had exercise induced asthma but that was not enough. On 14Jul2020, the patient had covid. The patient was sick for several days with a high fever that lasted a day and half at 102.4. Patient quarantined for 2 weeks but this did not last too long other than the loss of taste and smell that took 2 weeks to come back. Then 1-2 months later patient developed similar symptoms to what patient had now and that lasted almost a year, but it was not to the level he had now. Concomitant medication included losartan. The 7-10 days after the vaccine on an unknown date in Sep2021, the patient experienced headache, shortness of breath, heart palpitation, joint pain mostly in his shoulder, hips and knees and muscle pain, mostly in legs below the knees. Headache and heart palpitation has improved but shortness of breath had improved but not as much as the headaches, patient was used an inhaler more frequently and was given a steroid to took as treatment. The joint pain and muscle pain was interment, and the pain was the same though not constant. It was explained that patient did not really start putting it together until a week and a half to 2 weeks after the vaccine, that the vaccine was the cause. The patient had not changed in medication in the last 2 weeks. It was reported that patient went to the doctor and had lab work a week and a half ago. Patient had general labs, CBC, creatine, RA factor and everything was normal except his microalbumin in urine was high, but this was like this previously. His kidney function was normal and the issue with his microalbumin was something he had been dealing with for a couple years, so his doctor was not concerned. After had covid patient donated convalescent plasma as he still had high level of antibodies, they were doing blood test monthly. He would get a serology test for antibodies and with that test if he was over 1.0, he was said to have good antibodies. After getting the vaccine patient was tested and he was at 9.7. Before seeing his doctor patient had lab work a week and half ago and it showed him at 10.4. He did concern about taking the second dose and it was not recommended at this time by his doctor that he get the second dose. The doctor was going to do an echo to be sure there was no damage. The patient did not go emergency room for the events. The physician visited the physician office for the events.The patient underwent lab tests and procedures which included antibody test: 9.7 , antibody test: 10.4 , blood creatine: normal, full blood count: normal , laboratory test: normal , renal function test: normal, rheumatoid factor: normal, urine analysis: microalbumin in urine was high. All the test done on an unspecified date.The outcome of the events headache, dyspnoea and palpitations was recovering while the outcome of the events arthralgia and myalgia was not recovered.  Follow-up attempts were completed. No further information was expected.