Age: 67.0
Sex: F
Vaccine: COVID19
Symptoms: COVID-19, Chest X-ray, Computerised tomogram thorax, Cough, Depressed mood
Clinical narrative: New 5 and 7 mm ill-defined nodular densities are seen in the left upper\ increased calcification; Difficulty breathing; Feeling hot; Increased thoracic kyphosis noted; Anterior spondylosis is seen in the upper lumbar; likely infectious or inflammatory in etiology; patient has increased mucus production; very dry cough with just little tiny specs of mucus; felt slightly crappy; Fever; back muscle spasms; little sore arm; This spontaneous case was reported by an other health care professional and describes the occurrence of PNEUMONIA (likely infectious or inflammatory in etiology), PULMONARY CALCIFICATION (New 5 and 7 mm ill-defined nodular densities are seen in the left upper\ increased calcification), DYSPNOEA (Difficulty breathing) and COUGH (very dry cough with just little tiny specs of mucus) in a 67-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch no. 037K20A) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below.     The patient's past medical history included Chronic bronchitis (given gamma globulin shots, took up swimming and gradually the frequency for illness decreased (over a decade or so).), Pneumonia, Watering eyes, Runny nose and Hormone replacement therapy. Previously administered products included for an unreported indication: PNEUMOCOCCAL CONJUGATE VACCINE in October 2019. Concurrent medical conditions included Allergy to animal dander (Cat hair caused watery eyes, runny nose & stuffed head.) since 18-Dec-1972, Allergy to animal dander (dog hair caused watery eyes, runny nose & stuffed head.) since 18-Dec-1972, Allergy to animals (cattle caused watery eyes, runny nose & stuffed head.) since 18-Dec-1972 and Smoke inhalation (tobacco mix caused watery eyes, runny nose & stuffed head.) since 18-Dec-1972. Concomitant products included TRIAMCINOLONE ACETONIDE (TRIAMCINOLONE ACETONIDE (GLUCOCORTICOID)) from 05-Jan-2018 to an unknown date for Contact dermatitis, PREGNENOLONE from 09-Jan-2007 to an unknown date and PROGESTERONE from 09-Jan-2007 to an unknown date for HRT, KRILL OIL, UBIDECARENONE (COQ10 [UBIDECARENONE]) and CRANBERRY [VACCINIUM MACROCARPON] for Supplementation therapy, CYANOCOBALAMIN (VIT B12) and COLECALCIFEROL (VIT D3) for Vitamin supplementation.    On 28-Jan-2021 at 10:00 AM, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 28-Jan-2021, the patient experienced MUSCLE SPASMS (back muscle spasms) and PAIN IN EXTREMITY (little sore arm). On 29-Jan-2021, the patient experienced PYREXIA (Fever). On 31-Jan-2021, the patient experienced DEPRESSED MOOD (felt slightly crappy). On 01-Feb-2021, the patient experienced PRODUCTIVE COUGH (patient has increased mucus production) and COUGH (very dry cough with just little tiny specs of mucus) (seriousness criterion medically significant). On an unknown date, the patient experienced PNEUMONIA (likely infectious or inflammatory in etiology) (seriousness criterion medically significant), PULMONARY CALCIFICATION (New 5 and 7 mm ill-defined nodular densities are seen in the left upper\ increased calcification) (seriousness criterion medically significant), DYSPNOEA (Difficulty breathing) (seriousness criterion medically significant), FEELING HOT (Feeling hot), KYPHOSIS (Increased thoracic kyphosis noted) and SPINAL OSTEOARTHRITIS (Anterior spondylosis is seen in the upper lumbar). The patient was treated with IBUPROFEN ongoing since an unknown date for Adverse event, at a dose of UNK dosage form; BENZONATATE (oral) ongoing since an unknown date for Cough, at a dose of 200 mg; AZITHROMYCIN (oral) ongoing since an unknown date for Mucus discharge, at a dose of 250 mg and FLUTICASONE PROPIONATE (FLOVENT HFA) (oral) ongoing from 25-Feb-2021 for Adverse event, at a dose of 200mcg/act aer glax. On 29-Jan-2021, PAIN IN EXTREMITY (little sore arm) and PYREXIA (Fever) had resolved. On 30-Jan-2021, MUSCLE SPASMS (back muscle spasms) had resolved. On 31-Jan-2021, DEPRESSED MOOD (felt slightly crappy) had resolved. On 28-Apr-2021, PNEUMONIA (likely infectious or inflammatory in etiology), PRODUCTIVE COUGH (patient has increased mucus production), PULMONARY CALCIFICATION (New 5 and 7 mm ill-defined nodular densities are seen in the left upper\ increased calcification), DYSPNOEA (Difficulty breathing), COUGH (very dry cough with just little tiny specs of mucus), FEELING HOT (Feeling hot), KYPHOSIS (Increased thoracic kyphosis noted) and SPINAL OSTEOARTHRITIS (Anterior spondylosis is seen in the upper lumbar) had resolved with sequelae.      DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On 06-Feb-2021, COVID-19: negative (Negative) negative. On 11-Feb-2021, Chest X-ray: inconclusive (Inconclusive) New 5 and 7 mm ill-defined nodular densities are seen in the left upper lobe compared with 2007. On 15-Feb-2021, Computerised tomogram thorax: inconclusive (Inconclusive) Chest x-ray findings correspond with mild left upper lobe ground-glass opacities, likely infectious or inflammatory in etiology. Lungs, Pleura and Airways: Mild left upper lobe stellate peribronchovascular and subpleural ground-glass opacities. No airway narrowing or obstruction. No pleural effusion or pneumothorax..     The action taken with mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) was unknown.   For mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular), the reporter did not provide any causality assessments.   Patient started taking flu shots in her 50s which did help. On Monday 08 Feb 2021, patient called her PCP, and had a zoom call. She prescribed a cough med and suggested I get a chest xray and Ct scan. The medication helped a bit with the cough (especially at night) but she still had mucus production. Patient had another call with PCP on 16Feb 2021, where she prescribed a five day course of antibiotic, but that didn't result in clearing up the mucus production either. Patient was but on an inhaler to help clear up the likely infection/mucus. Patient had little to no (new) symtoms as a result of the 2nd shot. Patient used the inhaler for about two months and gradually the mucus production and cough went away. Patient weaned myself off the inhaler over the course of the first 2-3 weeks in May and was perfectly fine until she went in to have the pneumonia vaccine (PPSV-23) on 13 Jun 2021. After the shot patient's mucus production started up again and patient started back on the inhaler but only once a day, which seems to keep my symptoms in check. Patient met PCP on 29 Feb 2021, to talk about this on-going lung issue. Patient was going to take a pulmonary Function Test some time this month (July).  Based on the current available information and temporal association between the use of the product and the start date of the events,   a causal relationship cannot be excluded.  Further information has been requested.   This case was linked to MOD-2021-246799 (Patient Link).   Most recent FOLLOW-UP information incorporated above includes: On 05-May-2021: No new information. On 05-Jul-2021: Follow-up case - Second dose, height, weight, ethnic group, race, previous allergies, concomitant medications, treatment medications, new labs added. Action taken event outcome and inarrative updated.; Sender's Comments: Based on the current available information and temporal association between the use of the product and the start date of the events,   a causal relationship cannot be excluded.  Further information has been requested.