Age: 32.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Blood test, Chest discomfort, Chest pain, Dyspnoea, Electrocardiogram
Clinical narrative: infection in his foot; went to ER for high blood pressure; muscular skeletal inflammation; chest pains/pain mainly at rest but sometimes with a lot of exertion as well / pain had started out on the left side of his chest; chest pressure / tightness started occurring; very difficult for him to move around; very difficult for him to move around or even sleep /gets worse when he tries to sleep; difficulty breathing / breathing sometimes becomes painful due to this; palpitations, but they would eventually subside; he tried to lay down, his heart would start beating harder and faster; This spontaneous case was reported by a patient and describes the occurrence of MYOSITIS (muscular skeletal inflammation), CHEST PAIN (chest pains/pain mainly at rest but sometimes with a lot of exertion as well / pain had started out on the left side of his chest), CHEST DISCOMFORT (chest pressure / tightness started occurring), MOBILITY DECREASED (very difficult for him to move around) and INSOMNIA (very difficult for him to move around or even sleep /gets worse when he tries to sleep) in a 32-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch nos. 049E21A1 and 040E21A) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below.     The patient has not had COVID-19 positive test or diagnosis.  It was reported there were no other vaccines were given within 1 month prior to Moderna COVID-19 vaccine.  There were no history of COVID-19 infection, Myocarditis or pericarditis.  Concurrent medical conditions included Drug allergy (Acetaminophen) and Drug allergy (NSAIDs). Concomitant products included BUPRENORPHINE HYDROCHLORIDE, NALOXONE HYDROCHLORIDE (SUBOXONE) and ALPRAZOLAM for an unknown indication.   On 20-Jul-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) .5 milliliter. On 17-Aug-2021, received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) dosage was changed to .5 milliliter. In 2021, the patient experienced MYOSITIS (muscular skeletal inflammation), CHEST PAIN (chest pains/pain mainly at rest but sometimes with a lot of exertion as well / pain had started out on the left side of his chest), CHEST DISCOMFORT (chest pressure / tightness started occurring), MOBILITY DECREASED (very difficult for him to move around), INSOMNIA (very difficult for him to move around or even sleep /gets worse when he tries to sleep), DYSPNOEA (difficulty breathing / breathing sometimes becomes painful due to this), PALPITATIONS (palpitations, but they would eventually subside), HEART RATE INCREASED (he tried to lay down, his heart would start beating harder and faster) and HYPERTENSION (went to ER for high blood pressure). On an unknown date, the patient experienced LOCALISED INFECTION (infection in his foot). The patient was treated with KETOROLAC TROMETHAMINE (TORADOL) for Adverse event, at an unspecified dose and frequency; NAPROXEN at an unspecified dose and frequency; INDOMETHACIN [INDOMETACIN] at an unspecified dose and frequency; AMOXICILLIN;CLAVULANATE POTASSIUM for Foot infection, at an unspecified dose and frequency and DOXYCYCLINE for Foot infection, at an unspecified dose and frequency. At the time of the report, MYOSITIS (muscular skeletal inflammation), CHEST PAIN (chest pains/pain mainly at rest but sometimes with a lot of exertion as well / pain had started out on the left side of his chest), CHEST DISCOMFORT (chest pressure / tightness started occurring), DYSPNOEA (difficulty breathing / breathing sometimes becomes painful due to this) and PALPITATIONS (palpitations, but they would eventually subside) had not resolved and MOBILITY DECREASED (very difficult for him to move around), INSOMNIA (very difficult for him to move around or even sleep /gets worse when he tries to sleep), HEART RATE INCREASED (he tried to lay down, his heart would start beating harder and faster), LOCALISED INFECTION (infection in his foot) and HYPERTENSION (went to ER for high blood pressure) outcome was unknown.      DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On an unknown date, Blood test: came back normal, no signs of anything. On an unknown date, Electrocardiogram: came back normal, no signs of anything. On an unknown date, X-ray: came back normal, no signs of anything.         Symptom onset date was reported as Sep-2021 or Oct-2021.  The patient had been to the ER 4 to 5 times for the issue. After multiple visits to the ER and normal diagnostic tests, patient was told that he had Muscular Skeletal Inflammation.  The patient was currently on antibiotics for an infection in the foot.  It was reported that patient took Naproxen, Indomethacin, Toradol shot and patient would start Toradol orally for cardiac related symptoms.   This case was linked to MOD-2022-636326 (Patient Link).   Most recent FOLLOW-UP information incorporated above includes: On 29-Aug-2022: Follow-up received contains primary reporter details, patient details, added start date, dose, lot number of Moderna vaccine, events such as Mobility decreased, Difficulty sleeping, difficulty breathing, Palpitations, Exertional dyspnea , Heartbeats increased, Foot infection and Blood pressure high, treatment medications and lab data.