Age: 51.0
Sex: M
Vaccine: COVID19
Symptoms: Endoscopy, Eyelid ptosis, Investigation, Myasthenia gravis
Clinical narrative: Myasthenia gravis; double vision, cannot focus; left eye droop/right eye droop; Bell's Palsy came back with left eye droop/right eye droop; Bell's Palsy came back with left eye droop/right eye droop; This is a spontaneous report from a contactable consumer (patient). A 51-year-old male patient received the first dose of bnt162b2 (BNT162B2 reported as PFIZER COVID-19 VACCINE), via an unspecified route of administration in the left arm on 09Mar2021 08:48 am (lot number: EN6199) as a single dose for covid-19 immunisation. Medical history included facial paralysis from 20Jan2021 to an unknown date diagnosed initially as bell's palsy but now is diagnosed as myasthenia gravis and gastric reflux. Concomitant medication included unspecified gastric reflux medication and unspecified vitamins. The patient did not receive other vaccines within 4 weeks prior and did not receive other vaccine on the same day. The patient previously he was put on prednisone 60 mg tablets by mouth times 7 days, then 10 mg tablets for an additional 7 days. The patient mentioned he received the vaccine in a vaccination center. The patient reported that prior to his first shot towards the end of Jan2021, his doctor thought he had Bell's Palsy. On 20Jan2021, he stated that he was put on a high dose of steroids to clear it up. He stated that on 09Mar2021, he had his first Covid vaccine with no issues. On 12Mar2021 between 5-6 pm, he mentioned that it came back (the Bell's Palsy) with a vengeance, near his eye and with eye droop. He specifies left eye droop. He added that the Monday after (15Mar2021) over the weekend, it got worse. He mentioned that he talked with his neurologist who told him to speak with his ophthalmologist who the patient spoke to on Tuesday. The patient mentioned that both doctors came up with the diagnosis of Myasthenia Gravis. He inquired since one of his doctor's is concerned about him taking the second vaccine and the other doctor was ok with it. He mentioned that one doctor had a feeling of some bias, and the other doctor. He did some research in an association with people diagnosed with it. One of his doctors said that he is immunocompromised, so he looked at autoimmune information, and the information says it is ok. He reached out to the local medical center that is doing the vaccination and they are unwilling to talk with him over the phone. He has read on the association site and they seem to recommend to take it. He did not want to rebel against his doctor, so he wants to be sure. He inquired if it was safe for him to take his second dose and wanted to get good factual information that can give him a good starting point that is related. He mentioned that his second dose schedule was on 30Mar2021. He also stated that initial onset of Bell's Palsy with left eye droop, he was on a high dose steroid regimen and that seem to help which he finished up early Feb2021. It was mentioned that the event initial onset was not after the vaccine. The Ophthalmologist checked him on Tuesday and his left eye which he could barely open, and his doctor also noticed right eye droop. He stated without medication, it is worsening but with his medication, it is definitely helping to transmit between nerves. He stated before the medication this time of day he could not lift his left eye longer throughout the day, the more difficult it is for the muscles as they become weaker. There was noticeably drooping of the right eye. The ophthalmologist exam on his right eye was drooping which was ongoing. It is still there, his wife and he were comparing their eyes and how much he could open it, and it surprised them how little he could open it. It was different and strange. The time reported for the drooping of the right eye was 2:30 pm and persisting but the left eye was worse. He hasn't noticed a difference about the same, medication has been helping. It was also mentioned that myasthenia gravis reported that it started on the 16Mar2021 2:30 pm (talked to the Neurologist to compare notes, so maybe 3:30 - 4:00) when they made the initial diagnosis and started testing the next day. He is waiting for blood work to come back, but all the tests have pointed in that direction. Myasthenia gravis was ongoing, but the condition has worsened and the medications at a therapeutic level, it keeps it at bay. He further added that his eye became so hard to see, so he pyridostigmine bromide on 17Mar2021 since he couldn't open or focus, he thought he would give it a try. It works when he can't focus and if he doesn't take, it he will go back to where he was before. He will not be able to open his eye and the double vision will come back. The events required physician's office visit but did not require emergency room visit. He mentioned that there were 3 test and one more scheduled. The first one was a common test; the first initial test diagnose Myasthenia gravis. The second test was the ice test since they went on the assumption in their initial thinking it was Bell's Palsy and in his, doctor's, opinion it didn't look right. The test sounds goofy and it is one of the tests, they did to predict how it was going to go. He reported that they placed an ice cube in a cloth on the eye and let cool for 2-3 minutes. The eye lid is raised more than it was before the test and it went back down. This test was done on 16Mar2021. He reported that the did a chest x-ray on 17Mar2021 and looked for enlarge thalamus, he states it was normal. He has a CT scheduled next Wednesday (24Mar2021) to check his thalamus and lungs. The patient underwent lab tests and procedures which included blood test with unknown results on 17Mar2021, he reported that he is waiting for the results to look for antibodies for Myasthenia gravis; chest x-ray was normal on 17Mar2021, he reported that they did a chest x-ray and looked for enlarge thalamus, he states it was normal; endoscopy with results of no finding on Mar2021, his GI doctor wanted to do an upper and lower endoscopy, so 2 weeks prior to the vaccine he had an upper and lower endoscopy with no finding; and ice test with results of bell's palsy on 16Mar2021 and in his doctor's opinion, it didn't look right. The outcome of the events was not recovered.