Age: 57.0
Sex: M
Vaccine: COVID19
Symptoms: Haematocrit, Haemoglobin, Headache, Influenza A virus test, Influenza B virus test
Clinical narrative: Her husband passed away; Sepsis; Shock due to bilateral pulmonary acute disease syndrome; Shock due to bilateral pulmonary acute disease syndrome due to diffuse alveolar damage; misery and feeling horrible; Severe chills; Headache; Shortness of breath; Fever; Fatigue; Diarrhea; Muscle aches; Skin sensitivity and rash; Skin sensitivity and rash; Sore throat; This is a spontaneous report from a contactable consumer. A 57-year-old male patient received second dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration, administered in arm on 22Feb2021 at 10:00 (Lot Number: EN6202) (at the age of 57-year-old) as single dose for COVID-19 immunisation.  Medical history included high cholesterol from 2017 to an unknown date, seasonal allergy from an unknown date and unknown if ongoing and arteriosclerosis from 2017 to an unknown date. The patient's concomitant medications were not reported.  The patient previously received first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on 01Feb2021 (Lot Number: EL9264) (at the age of 57-year-old) as single dose for COVID-19 immunisation; the patient previously received ZYRTEC (10mg almost daily) for seasonal allergy, ibuprofen (ADVIL, 200 mg) and TYLENOL both for pain. Caller stated that the patient passed away on 02Mar2021 which was 8 days after the 2nd dose of the Pfizer COVID Vaccine. On 26Feb2021 the patient went to urgent care and then on 01Mar2021 he went to the hospital emergency room (ER).  It was reported that an autopsy was performed on 06Mar2021 and the cause of death listed sepsis and complications from sepsis and shock due to bilateral pulmonary acute disease syndrome due to diffuse alveolar damage.  The manner of death was natural and the lung presentation is highly suggestive of diffuse alveolar damage due to COVID-19 although the patient had several negative tests for COVID. The patient tested negative for influenza AB, negative for valley fever, negative for Legionnaire's disease and was in the hospital for less than 24 hours. The patient went back to urgent care on 28Feb2021 and was feeling miserable and asking for blood tests and urine tests, stated at that time his platelets were low at 122, glucose was high at 105, sodium was low at 134, calcium was low at 8.3, urine was negative and the patient did not get these labs til Monday when he was on the way to the emergency room and it was all different when he got to the hospital. The test for strep was negative, the oxygen was low at 86 percent when he got to the hospital on Monday and they just had to keep increasing his oxygen, stated a culture, no further details provided about the culture. A CTA done on the chest on Monday which was bad and stated the patient was symptomatic and they did not treat him for COVID but had a clinical suspicion for COVID. Adenovirus was not detected, metapneumonia virus was not detected, respiratory syncytial virus was not detected, parainfluenza was not detected, his platelets kept dropping and he had two tests for valley fever which is Cocci IGG and IGM and those were negative, the sodium level on 02Mar2021 was 126, all of these things were low: chloride 92, CO2 18, calcium 7.8, glucose was high at 222, bun was high at 21, creatinine was high at 1.4, EGFR was low at 52, WBC was high at 18.6, RBC was high at 7.39, HGB was 22.6, HCT was 66.4, RDW was high at 15, RDWFD was 45.5, and platelets were low at 61. The patient came into the emergency room those labs were when he was failing completely and on 01Mar2021 was when he arrived in the ER; at that time his WBC were normal, RBC was high at 6.16, HGB was high at 18.5, HCT was high at 54.9, platelets were low at 73, monocytes absolute were high at 0.96, sodium was low at 129, chloride was low at 95, calcium was low at 8.3, glucose was high at 150 and this was 7 days past the Pfizer COVID Vaccine. The patient was negative for strep pneumonia antigen and negative for Legionnaires Urinary antigen. The chest X-ray was done on 26Feb2021 and the patient was in misery and feeling horrible and they sent him home with albuterol and possible antibiotic to start that Monday and he had severe chills, headache, shortness of breath, fever, fatigue, diarrhea, muscle aches, skin sensitivity and rash, sore throat. Chest X-ray says normal; states the albuterol was PROAIR HFA 90mcg and he tested negative for influenza AB and he never got to the antibiotic because they said to wait til Monday and by that time this was an emergency. The patient outcome of sepsis and shock due to bilateral pulmonary acute disease syndrome due to diffuse alveolar damage was fatal and unknown for the other events. The patient died on 02Mar2021.  An autopsy was performed that revealed the cause of death was sepsis and complications from sepsis and shock due to bilateral pulmonary acute disease syndrome due to diffuse alveolar damage.; Reported Cause(s) of Death: Sepsis; Autopsy-determined Cause(s) of Death: Shock due to bilateral pulmonary acute disease syndrome; Diffuse alveolar damage