Age: 44.0
Sex: F
Vaccine: COVID19
Symptoms: Protein total, Pyrexia, Red blood cell count, Rheumatoid factor, SARS-CoV-2 test
Clinical narrative: Epstein Barr Virus (EBNA) AB(IgG) EPSTEIN BARR VIRUS(EBNA): 217.00 H (U/ml), Epstein Barr Virus VCA AB (IgG): EPSTEIN BARR VIRUS VCA: 36.80 H (U/ml); Five days after my first vaccine dose I began a fever running between 99.7 and 100.3 F. I have been running this fever daily since then - now for more than 10 weeks; I feel exhausted; achy; brain fog; The initial safety information received was reporting only non-serious adverse drug reactions. Upon receipt of follow-up information on 21Sep2021, this case now contains serious adverse reaction. Information processed together.  This is a spontaneous report from a contactable consumer (patient) and other healthcare professional. A 44-year-old non-pregnant female patient received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE; lot number: ER8734) via an unspecified route of administration, administered on the right arm on 01Apr2021 (at the age of 44-years-old) as dose 1, single for COVID-19 immunization. Medical history included dry eyes, high cholesterol, psoriasis, generalized anxiety, migraines, IBS (IBS well controlled since taking Zoloft colonoscopies have been normal neg sibo breath test nml no dietary triggers), Vitamin D Deficiency, hyperlipidemia, bone up calcium magnesium sup. Concomitant medications included sertraline hydrochloride (ZOLOFT); vitamin D NOS; vitamin B NOS; probiotics NOS; calcium; vitamin D2; thiamine (VITAMIN B1 [THIAMINE]); calcium carbonate, colecalciferol (CALCIUM 600 + D) taken for bone up calcium magnesium sup; clonazepam (KLONOPIN). The patient previously took codeine and experienced Allergies: codeine: racing heart; Allergies: Diflucan: rash; xifaxan and Allergies: xyfaxan: Rash; zoloft for IBS. It was reported that five days after her first vaccine dose (06Apr2021) she began a fever running between 99.7 and 100.3 F. She had been running this fever daily since then - now for more than 10 weeks. She felt exhausted, brain fog, achy. She had been to her family doctor, and an infectious disease specialist. Have had a CT scan of chest and abdomen, and dozens of bloods checking everything from viruses like malaria or Lymes disease, to inflammatory markers, UTIs, rheumatoid arthritis, WBC and RBC counts and more. All tests were normal. The events resulted to a doctor or other healthcare professional office/clinic visit. No treatment was received. The event fever was considered serious, medically significant. Prior to vaccination, the patient was not diagnosed with COVID-19. Since the vaccination, the patient been tested for COVID-19, PCR Nasal swab: negative. The patient underwent lab tests and procedures which included: Result Date: 29Jul2021 Color: Yellow, Appearance: Cloudy A (Clear), Bilirubin:  Negative, Ketones:  Negative, Specific Gravity: 1.006 (1.001-1.035), Occult Blood: Negative, pH: 5.5 (5.0-8.0), Protein:  Negative, Nitrite: Negative, Leukocyte Esterase: Negative, WBC: None seen (<OR=5/HPF), RBC: None seen (<OR=2/HPF), Squamous Epithelial Cells: None seen (<OR=5/HPF), Bacteria: None seen (None seen/HPF), Hyaline Cast:  None seen (None seen/LPF), Glucose: Negative, Culture: unknown result. Result date: 26Jun2021: PDF Report#: LCLS, HDL-P (Total): 41.8 (>=30.5umol/L), LDL Size: 21.9 (>20.5nm) , LDL-P: 1802 H (<1000nmol/L), LP-IR score: <25(<=45), small LDL-P: 313(<=527nmol/L), HDL-C: 81(>39mg/dL), Triglycerides: 99(0-149mg/dl), Cholesterol, Total: 274 H (100-199mg/dL), LOL-C (NIH calc): 176 H (0-99mg/dL); HIV AG/AB, 4TH GEN: Non-reactive(Non-reactive), Quantiferon(R)-Tb Gold Plus, 1 Tube: Negative, Nil: 0.01(IU/ml), Mitogen-nil: 2.34(IU/ml), TB1-NIL: 0.0(IU/ml), TB2-NIL: 0.0(IU/ml). Result date: 21Apr2021 ANA SCREEN, IFA: Negative, Ferritin: 45 (16-232ng/ml), Cyclic Citrullinated Peptide (CCP) AB (IgG): <16(<20 units), RHEUMATOID FACTOR (IgA): <5(<=6U), RHEUMATOID FACTOR (IgG): <5(<=6U), RHEUMATOID FACTOR (IgY): <5(<=6U), SJOGREN'S ANTIBODY (SS-A): <1.0 (AI), SJOGREN'S ANTIBODY (SS-B): <1.0 (AI); Source: Whole blood, EBV DNA, QN PCR: <200(<200Copies/ml), EBV DNA, QN PCR: <2.30(<2.30 Log cps/ml); EPSTEIN BARR VIRUS(EBNA) AB(IgG) EPSTEIN BARR VIRUS(EBNA): 217.00 H (U/ml), EPSTEIN BARR VIRUS VCA AB (IgM): EPSTEIN BARR VIRUS VCA: <36.00 (U/ml), EPSTEIN BARR VIRUS VCA AB (IgG): EPSTEIN BARR VIRUS VCA: 36.80 H (U/ml); Anti-Streptolysin O: <50(<200IU/ml), Glucose: 78(65-99mg/dL), Urea Nitrogen (BUN): 11(7-25mg/dL), Creatinine: 0.81(0.50-1.10 mg/dl), eGFR Non-Afr. Am: 88(>OR = 60ml/min/1.73m2), eGFR Afr Am: 88(>OR = 102ml/min/1.73m2), BUN/Creatinine Ratio: Not applicable(6-22(calc), Sodium: 140(135-146mmol/L), Potassium: 3.9(3.5-5.3 mmol/L), Chloride: 104(98-110mmol/L), Carbon Dioxide: 28(20-32mmol/L), Calcium: 10.2(6.6-10.2mg/dl), Protein, Total: 7.0(6.1-8.1 g/dl), Albumin: 4.5(3.6-5.1 g/dl), Globulin: 2.5(1.9-3.7 g/dl (calc)), Albumin/Globulin Ratio: 1.8(1.0-2.5(calc)), Bilirubin, Total: 0.4(0.2-1.2 mg/dl), Alkaline Phosphatase: 59(31-125 U/L), AST: 15(10-30 U/L), ALT: 11(6-29 U/L); Bacteria: None seen (None seen/HPF), Culture: NR, Leukocyte Esterase: Negative, Nitrite: Negative, WBC: None seen(<0R=5/HPF), Color: Yellow, Appearance: clear, Bilirubin: Negative, Ketones: Negative, Specific Gravity: 1.005(1.001-1.035), Occult Blood: Negative, pH: 6.5(5.0-8.0), Protein: Negative, RBC: None seen (<OR=2/HPF), Squamous Epithelial Cells: None seen (<OR=5/HPF), Calcium Oxalate Crystals: NR, Hyaline cast: None seen (None seen/LPF), Glucose: Negative; RDW: 12.3(11.0-15.0%), Platelet Count: 340(140-400 Thousand/ul), Neutrophils: 62.7(%), Absolute Neutrophils: 4828(1500-7800 cells/ul), Lymphocytes: 27.3(%), Absolute Lymphocytes: 2102(850-3900 cells/ul), Monocytes: 7.7(%), Absolute Monocytes: 593(200-950 cells/ul), Eosinophils: 1.3(%), Absolute Eosinophils: 100(15-500 cells/ul), White Blood Cell Count: 7.7(3.8-10.8 Thousand/ul), Basophils: 1.0(%), Red Blood Cell Count: 4.56(3.80-.10 Million/ul), Absolute Basophils: 77(0-200 cells/ul), Hemoglobin: 14.1 (11.7-15.5g/dl), Hematocrit: 42.8(35.0-45.0%), MCV: 93.9(80.0-100.0fL), MCH: 30.9(27.0-33.0pg), MPV: 10.5(7.5-12.5 fL), MCHC: 32.9(32.0-36.0g/dl), C-Reactive protein: 1.2(<8.0mg/L). Result date: 11Apr2021 Bacteria: None seen (None seen/HPF), Culture: NR, Leukocyte Esterase: Negative, Nitrite: Negative, WBC: None seen (<0R=5/HPF), Color: Yellow, Appearance: clear, Bilirubin: Negative, Ketones: Negative, Specific Gravity: 1.004(1.001-1.035), Occult Blood: Negative, pH: 6.5(5.0-8.0), Protein: Negative, RBC: None seen (<OR=2/HPF), Squamous Epithelial Cells: 0-5(<OR=5/HPF), Calcium Oxalate Crystals: NR, Hyaline cast: None seen (None seen/LPF), Glucose: Negative. Outcome of the event fever was recovering, Epstein-Barr virus infection was unknown while not recovered for the other events.   Follow-up attempts are completed. No further information is expected.