Age: 73.0
Sex: M
Vaccine: COVID19
Symptoms: Pain in extremity, Polymyalgia rheumatica, Renal function test, Rheumatoid factor, SARS-CoV-2 test
Clinical narrative: muscle issue/Muscle fatigue in hips; The hips, glutes and shoulders were sore; The hips, glutes and shoulders were sore; The hips, glutes and shoulders were sore; pain in the arm; Booster; Polymyalgic Rheumatoid; not able to sleep; pain in shoulders, back and neck would hurt; pain in shoulders, back and neck would hurt; This is a spontaneous report received from contactable reporter (Consumer). The reporter is the patient.  A 73 year-old male patient received bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE), administered in arm left, administration date 20Oct2021 11:15 (Lot number: FF2593) at the age of 73 years as dose 3 (booster), single for covid-19 immunisation. The patient had no relevant medical history. Family medical history: Father had emphysema, but he made it to 80 and was a 5 pack a day smoker. The patient took concomitant medications (just take vitamins). Vaccination history included: Bnt162b2 (1st dose, Injected in the Left arm in the muscle.), administration date: 14Feb2021, when the patient was 73 years old, for COVID-19 Immunization, reaction(s): "pain in the arm"; Bnt162b2 (2nd dose, lot#: EN6203 , Injected in the Left arm in the muscle.), administration date: 28Feb2021, when the patient was 73 years old, for COVID-19 Immunization, reaction(s): "Left arm pain/ arm was sore for 3-4 days"; Flu, administration date: 15Sep2021, when the patient was 73 years old, for Vaccination. He was told to wait a month to get COVID booster and they did that. Prior Vaccinations (within 4 weeks), no other vaccinations within four weeks prior to the first administration date of the suspect vaccine(s). No additional Vaccines Administered on Same Date of the Pfizer Suspect. The following information was reported: IMMUNISATION (medically significant) with onset 20Oct2021 11:15, outcome "unknown", described as "Booster"; POLYMYALGIA RHEUMATICA (medically significant) with onset 2021, outcome "unknown", described as "Polymyalgic Rheumatoid"; INSOMNIA (medically significant) with onset 2021, outcome "unknown", described as "not able to sleep"; PAIN IN EXTREMITY (medically significant) with onset 21Oct2021 07:00, outcome "recovered" (Oct2021), described as "pain in the arm"; MUSCLE FATIGUE (medically significant) with onset 08Nov2021, outcome "not recovered", described as "muscle issue/Muscle fatigue in hips"; ARTHRALGIA (medically significant), MUSCULOSKELETAL PAIN (medically significant) all with onset 08Nov2021, outcome "recovering" and all described as "The hips, glutes and shoulders were sore"; ARTHRALGIA (medically significant) with onset 08Nov2021, outcome "not recovered", described as "The hips, glutes and shoulders were sore"; NECK PAIN (medically significant), BACK PAIN (medically significant) all with onset 2021, outcome "unknown" and all described as "pain in shoulders, back and neck would hurt". Clinical details as follows: He received first and second dose in Feb2021, and in Oct2021, he received the booster.He had booster on 20Oct2021 and like anyone else, had the pain in the arm after the shot. No big deal. He got it with first shot too, then later clarified it was not so much with first dose, but with 2nd and 3rd doses. Two weeks after getting the booster, he started to have muscle fatigue in hips, glutes, shoulders and the long and short of it is, after much blood work, they identified it as Polymyalgic Rheumatoid.He never had any rheumatoid factors prior to this.All of a sudden, he was lit up like a church candle.He is under care of a doctor at withheld and is on a steroid. He was in such pain, he was not focusing on reporting. He was just focusing on getting better.It took going to doctor visits and getting blood work.A week ago, they started him on steroids and he started feeling like a human being again. He is right handed.He got all of them in the left arm in the muscle. The next day after getting 2nd dose, his right arm was sore for 3-4 days.After the 3rd dose on 20Oct2021, his right arm was sore the next day, but that one lasted 6-7 days.It has improved. That went away.Then it was a week or so later, that he started to experience this muscle issue.It reached the point, for a couple of days, he was walking with a cane and concerned he would fall.The hips, glutes and shoulders were sore.He was kind of incapacitated.It started about 2 to 2 1/2 weeks out.Now that he is on Prednisone, he is pain free.He did not start it until 30Nov2021.It had reached the point where he was not able to sleep.He was sitting up on the couch sleeping.He could not sit because his glutes were sore.When getting up, when you stood up, you had to take a step or two so the muscles started to fire again before you could walk.That was bad enough.The glutes and hips were first, then shoulder and neck came second.That put the final cherry on the top.Think about standing, if your legs are hurting, you would use arms to support, but because of the pain in shoulders, back and neck would hurt, he was afraid to lean.He told his doctor he was at an emergency level.He was afraid he would fall.So that is when they started the Prednisone. Sore arm after 2nd and 3rd dose. Probably the next morning when he woke up at 07:00. Muscle fatigue in hips, glutes, shoulders and neck was reported as worsened. Physician Office? Yes. Muscle fatigue in hips, glutes, shoulders and neck. They did blood work. He saw (name).He contacted his Primary Care and they concurred. At that point, it was Saturday, 20Nov2021, and that is when his doctor said before they can prescribe it, he needs to go to a walk in clinic and he wants him to get blood work.He cannot recommend medication until he gets blood work.They did Lupus, Lyme, and COVID test and tested for white blood cell, liver and kidney function.Then they did this Rheumatoid battery, which is about 8-9 different things.All other were negative.White cells were good and all others were fine, but Rheumatoid panel said Polymyalgia popped up. They recommended he go to a rheumatologist.He got a date for 08Feb2022, and he said that was not good because he could not move.He got a doctor, (name).He looked at reads on initial blood work and he wanted an additional round of blood work, which they did that day.They wanted him to hold off on any treatment.So he saw him on 24Nov2021, he had him on Aleve and Tylenol and said to wait until he gets blood work back.By Saturday, 27Nov2021, he called him and he was off duty, he got someone else and he told them he was in a bad way, but she said to hang on until Monday 29Nov2021.He was started on Prednisone on 30Nov2021.It was 4mg and started out with him taking it all at on time, in the morning.This started on 30Nov2021, then he saw him again on 03Dec2021, the pain in the glutes and hips had subsided significantly, like 90%, but not in the shoulder and arm, so they went to doing 2 in the morning and 2 at night.So they stayed on 4mg a day, total of 16 mg, but it was split.That was on the 03Dec2021, and by Monday 06Dec2021, he was started to feel human again.He will be on it for a long time.It is in a pharmacy vial with no lot or expiration. Lab values for the Rheumatoid panel, his doctor specifically said 50 and over would be a significant factor, his were 34-35.