Age: 44.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Endoscopy upper gastrointestinal tract, Eyelid ptosis, Fall, Gait disturbance, General physical health deterioration
Clinical narrative: couldn't see and couldn't walk; a lot of pain and stiffness in her back from the fall; a lot of pain and stiffness in her back from the fall; herniated disc/multiple herniated discs from the fall; gallstone; pain all the time; heavy feeling on her head/head pressure on the top of her head; trouble remember things/having a lot of trouble remembering and trying to keep focus; trouble remember things/having a lot of trouble remembering and trying to keep focus; is rapidly deteriorating; muscle pain; muscles being damaged; could not sleep; right eye is drooping a little bit; right arm and right leg are in a lot of pain; head are inflamed; couldn't see and couldn't walk; couldn't eat/could not drink water or eat; she was 217 and she couldn't eat, so she is now 203; headaches and migraines; headaches and migraines; couldn't pass gas was having pain and in chest and stomach; couldn't pass gas was having pain and in chest and stomach; muscle tightness/muscle tightness on the right side and in both of legs/muscle tightness in the trapezius muscle and neck; nerve damage; legs are weak; vomiting / felt like she was going to vomit; tight feeling in her chest couldn't breath; tight feeling in her chest couldn't breath; hit her head/two bumps on her head with no blood; hip and back were bleeding; two abrasion one on her back and the other on her hip; a lot of pain and stiffness in her back from the fall; fainting/passing out/felt like she wanted to pass out; fainting/passing out/felt like she wanted to pass out; This is a spontaneous report from a contactable consumer (patient). A 44-year-old female patient received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE), intramuscular, administered in arm right, administration date 30Apr2021 (Lot number: EW0175) at the age of 44 years as DOSE 2, SINGLE for COVID-19 immunisation. No prior vaccinations (within 4 weeks). Relevant medical history included: "Ovarian cyst removal" (not ongoing), notes: 10 years ago; "herniated disc" (unspecified if ongoing), notes: ten years ago, no problems with it, no surgery; "measles" (unspecified if ongoing), notes: when she was young. Family history included heart attacks with her aunts and uncles. There were no concomitant medications. Vaccination history included: BNT162B2 (dose 1, lot number: EW0150, muscle in the right arm), administration date: 09Apr2021, when the patient was 44 years old, for COVID-19 immunization. The following information was reported: SYNCOPE (medically significant), LOSS OF CONSCIOUSNESS (medically significant) all with onset 01May2021, outcome "unknown" and all described as "fainting/passing out/felt like she wanted to pass out"; BLINDNESS (medically significant), GAIT DISTURBANCE (non-serious), outcome "unknown" and all described as "couldn't see and couldn't walk"; FALL (medically significant) with onset 01May2021, outcome "unknown", BACK PAIN (medically significant), MUSCULOSKELETAL STIFFNESS (medically significant), outcome "unknown" and all described as "a lot of pain and stiffness in her back from the fall"; HEAD INJURY (medically significant) with onset 01May2021, outcome "unknown", described as "hit her head/two bumps on her head with no blood"; HAEMORRHAGE (medically significant) with onset 01May2021, outcome "unknown", described as "hip and back were bleeding"; SKIN ABRASION (medically significant) with onset 01May2021, outcome "unknown", described as "two abrasion one on her back and the other on her hip"; INTERVERTEBRAL DISC PROTRUSION (medically significant), outcome "unknown", described as "herniated disc/multiple herniated discs from the fall"; VOMITING (medically significant) with onset 01May2021, outcome "unknown", described as "vomiting / felt like she was going to vomit"; CHEST DISCOMFORT (non-serious), DYSPNOEA (non-serious) all with onset 01May2021, she went to the emergency room had an ultrasound which revealed a gallstone, outcome "unknown" and all described as "tight feeling in her chest couldn't breath"; CHOLELITHIASIS (non-serious), outcome "unknown", described as "gallstone"; PAIN (non-serious), outcome "unknown", described as "pain all the time"; CHEST PAIN (non-serious), ABDOMINAL PAIN UPPER (non-serious) all with onset 01May2021, had an Endoscopy everything was clear couldn't find anything, pain was dominate in chest and stomach eased up in Aug2021, outcome "recovering" and all described as "couldn't pass gas was having pain and in chest and stomach"; MUSCLE TIGHTNESS (non-serious) with onset 01May2021, outcome "not recovered", described as "muscle tightness/muscle tightness on the right side and in both of legs/muscle tightness in the trapezius muscle and neck"; NERVE INJURY (non-serious) with onset 01May2021, outcome "unknown", described as "nerve damage"; MUSCULAR WEAKNESS (non-serious) with onset 01May2021, outcome "unknown", described as "legs are weak"; HEAD DISCOMFORT (non-serious), outcome "not recovered", described as "heavy feeling on her head/head pressure on the top of her head"; MEMORY IMPAIRMENT (non-serious), DISTURBANCE IN ATTENTION (non-serious), outcome "unknown" and all described as "trouble remember things/having a lot of trouble remembering and trying to keep focus"; GENERAL PHYSICAL HEALTH DETERIORATION (non-serious), outcome "unknown", described as "is rapidly deteriorating"; MYALGIA (non-serious), outcome "unknown", described as "muscle pain"; MUSCLE INJURY (non-serious), outcome "unknown", described as "muscles being damaged"; INSOMNIA (non-serious), outcome "unknown", described as "could not sleep"; EYELID PTOSIS (non-serious), outcome "unknown", described as "right eye is drooping a little bit"; PAIN IN EXTREMITY (non-serious), outcome "unknown", described as "right arm and right leg are in a lot of pain"; HEADACHE (non-serious), MIGRAINE (non-serious) all with onset Sep2021, outcome "unknown" and all described as "headaches and migraines"; INFLAMMATION (non-serious), outcome "unknown", described as "head are inflamed"; EATING DISORDER (non-serious), outcome "unknown", described as "couldn't eat/could not drink water or eat"; WEIGHT DECREASED (non-serious), outcome "unknown", described as "she was 217 and she couldn't eat, so she is now 203". The patient stated on 01May2021 she began experiencing vomiting, went to wash her hands use the restroom and when she woke up she was face down on the ground from fainting/passing out, the toilet seat and tissue holder was broke off, she called for her husband who got her to the couch where she continued to vomit, had two bumps on her head with no blood, there were two abrasion one on her back and the other on her hip. The patient then stated that on 01May2021, after she got up, felt like wanted to pass out and like was going to vomit, went to the bathroom and was getting ready for bed. She did not make it back to bed, looked down at the ground and passed out, hit her head and could feel the bump and her hip and back were bleeding, called her husband and she continued to vomit, could not drink water or eat or do anything. Eventually, she got up and in the bathroom, everything was broken, like the toilet sink, the toilet paper holder was on the ground and everything was on the floor, she landed on the floor. A couple of days after that, she had a lot of pain and stiffness in her back from the fall. Her chest was ok but, a day later, her chest started getting tight and her back started getting really tight. She ended going to the emergency room different times since then. At one time, she went to the Emergency room and they did an ultrasound and said that it was gallstones causing all of this tightness. It persisted for months, the tightness in the chest above the breast area and it was stabbing as still. She could not sleep at all and she couldn't sit still for too long. She couldn't even get up and down because everything felt constricted, like someone was squeezing or stabbing her chest. They did an upper endoscopy and didn't find anything. They did a bunch of different tests, the upper endoscopy came back fine. They did a CT scan with contrast that came out fine. There were no ulcers and there was nothing going on. The tightness persisted a lot and the back tightness has been going on a long time. In Aug2021, it started to ease up a bit in the chest and her back got really tight and took over all the pain. It is more dominant in the back now. She saw a specialist and they did MRIs and at this point, the MRI found multiple herniated discs from the fall. In the thoracic lumbar region, she had multiple herniated discs. She saw a spine specialist and the neurologist was saying there was a lot of muscle activity and was now seeing the problem with the muscle pain and the muscles being damaged. They also said the nerves were being affected, as well as the muscle. The caller states that the doctor said he could hear the roaring of the muscles that were out of control, stating he had never heard anything so active. She saw a second neurologist who also believed that it was muscle tightness in the trapezius muscle and neck. The seen so many different doctors but has no official diagnosis. Last Monday, she saw an orthopedic doctor who said her trapezius muscles were extremely tight and her neck felt so tight, especially on the right side. After the vaccine, she has had a lot of muscle tightness in the thoracic and neck and back. She has been to physical therapy, which helps for a while but, after that everything contracts an tightens up. She has a lot of muscle problems. She had been asking all these different doctors about this and has tried to reach out to all these different doctors trying to get help. Prior to this, she had no pre existing health conditions and her pressure was fine. Her health was fine. At this point, she is not a functioning person and could barely even get to physical therapy sometimes. Everything is on the right side. Her right eye is drooping a little bit and her right arm and right leg are in a lot of pain. Her trapezius muscles in the back and neck and radiate up to the head are inflamed or because of the muscle problems that have gone to the top of the head and are tight. She had been having a lot of trouble remembering and trying to keep focus, was still having the pain and tightness in the stomach and back but, mostly in the back, almost a nonfunctioning person right now. Even with physical therapy, she can't do anything. She was just home, trying to massage the muscles. She stated that the doctors said it wasn't the gallstones giving her all of her symptoms that she probably had the gallstones before. In Sep2021, she had back pain and tightness on the right side of her back, the pain was so dominating in the chest and it was just there and it was tight in the back, she had head problems early in Sep2021, with headaches and migraines. She went to 5 different Emergency Rooms. Her chest was not as tight and she can't eat. In the morning, her muscles tighten up and in the morning, she has no appetite at all. She can't eat breakfast, she could drink but that was it. In the day time, it went away and she was able to eat something. Now, the symptoms she was having still was back tightness, neck tightness and head pressure. Clarified that she said she was having migraines but they were not really migraines. The muscles were so tight that they really tighten up to the neck and back and put pressure on the top of the head. In the ER, they did, not an EKG but a test of the vessels in the neck that came back ok. She had a lot of muscle problems. On Monday, the rheumatologist mentioned it could be the nerves and muscles being interconnected. She led a normal life before this and that she can't even go to the super market without muscles getting so tight. She was so weak, her muscles in the legs were very weak and with the tightness in her head, can't even function or focus, can't drive or nothing, muscles were not functioning at this point. She had physical therapy but can't even make it to that. Sometimes, because the tightness was really dominating the right side, her right arm was very stiff and can't write. Her right leg was very weak with pins and needles, was very weak on the right side and the head pressure on the top of her head, at the base of the skull. Most of the times it was on that right side. Patient clarified that the 5 times the caller had gone to the emergency room, she was nod admitted to the hospital, it was just to the emergency room. The events (except eating disorder and weight decreased) were evaluated at the physician office visit and emergency room visit. The patient underwent the following laboratory tests and procedures: CT scan with contrast: fine; upper endoscopy: everything was clear couldn't find anything; MRI of head: clear; MRI of spine: herniated disc; ultrasound: gallstones; a test of the vessels in the neck: ok; weight: 203. Therapeutic measures were taken as a result of back pain, musculoskeletal stiffness, intervertebral disc protrusion, pain, chest pain, abdominal pain upper, muscle tightness, nerve injury, muscular weakness, myalgia, pain in extremity, headache, migraine. ain in extremity, headache, migraine and included treatment with Benadryl, Toradol and Reglan, a lot of different medications, cyclobenzaprine, pain medications, tramadol (which was a one time pain medication they gave her in the ER), nortriptyline (didn't work good either) and physical therapy. Patient said one time, she got up in the morning and couldn't see and couldn't walk, felt the pressure at the top of her head and could not look up, they treated that as a migraine and that day in the ER, they gave her Benadryl, Toradol and Reglan which did help that day but she was back to square one the next day, clarified that she had been given Benadryl Toradol and Reglan that did help but did not last. They gave her many different medications, there were a lot of different doctors and a lot of different medications, they gave her cyclobenzaprine, which made it worse, after 5 days, she was literally trembling and could not continue that so they stopped that medication. One time in the ER, they gave her gabapentin and she had not started that yet, they gave that to her Monday.   Follow-up attempts are completed. No further information is expected.