Age: 72.0
Sex: F
Vaccine: COVID19
Symptoms: Aphonia, Balance disorder, Cerebrospinal fluid leakage, Chills, Condition aggravated
Clinical narrative: oral Lichen Planus was more pronounced; She hurt more, too, in her L4 & L5 vertebrae; aphonia, loses her voice; everything went black for a second; equilibrium being off; lightheadness; exasperated her spinal cord leak symptoms; exasperated her spinal cord leak symptoms, Oral Lichen Planus was more pronounced, hurt more, too, in her L4 & L5 vertebrae; headache; chills; had pain throughout her whole body; not feeling well; This is a spontaneous report from a non-contactable consumer (patient). A 72-year-old female patient received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, Solution for injection; lot number ER2613 and expiry date not reported), via an unspecified route of administration, administered in Arm Left on 24Mar2021 13:53 (at the age of 72-year-old), as dose 2, single, for COVID-19 immunisation. Medical history included ongoing spinal leak (diagnosed about 1-1/2 years ago and had spinal leaks, on and off, since that time), ongoing oral lichen planus (diagnosed between 10-15 years ago), ongoing rheumatoid arthritis (diagnosed at least 3 years before she was diagnosed with oral lichen planus). The patient had been tested for food allergies and as long as she stayed away from gluten, chicken, tomatoes and some other things, she did not have a problem with her rheumatoid arthritis. Gluten, in particular, triggered her rheumatoid arthritis. The patient fractured her L4 vertebrae in last summer 2020, sciatica from Feb2020 (pinched sciatic nerve since Feb2020) and had bone density issue. The patient's family have a history of autoimmune diseases, like Lupus. Concomitant medications included diphenhydramine; paracetamol (TYLENOL; lot number: SLA006, expiration date: Aug2024); ibuprofen (ADVIL [IBUPROFEN]; lot number: EG1007, expiration date: Jul2023); gabapentin (expiration date: 05Mar2022). Historical vaccine included BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, Solution for injection; lot number EN6198 and expiry date not reported), via intramuscular, administered in Arm Left on 02Mar2021 (at the age of 72-year-old), as dose 1, single, for COVID-19 immunisation and experienced left arm sore; the patient previously took (15 years ago) Flu vaccine and experienced mouth sores. On 24Mar2021, late the night of her second COVID-19 Vaccine shot, the patient experienced typical side effects of a headache, chills, not feeling well, and her body was aching. It was reported that, those side effects were mild, and resolved in about 2 days. On 25Mar2021 at about 11:30AM, the patient blacked out and just sat down in a chair, and everything went black for a second. It was reported that, second COVID-19 Vaccine exasperated her spinal cord leak symptoms because her lightheadedness, and equilibrium being off. She hurt more, too, in her L4 and L5 vertebrae, had pain throughout her whole body and her oral lichen planus was more pronounced since her second COVID-19 vaccine dose. The patient lost her voice/aphonia on an unspecified date. She clarified that her doctors didn't think the spinal cord leaks would be contraindicated with the COVID-19 Vaccine and all her doctors said it was up to her if she wanted to get the COVID-19 Vaccine because she previously had problems with the flu vaccine (mouth sores and it got worse, and the local doctors didn't know how to treat). The outcome for headache, chills, not feeling well, and her body was aching was recovered, while for other events was not recovered.  No follow-up attempts are possible. No further information is expected.