Age: 43.0
Sex: M
Vaccine: COVID19
Symptoms: Immunology test, Iron deficiency, Magnetic resonance imaging, Proctitis, Vitamin B complex deficiency
Clinical narrative: It looked as he had strokes/Brain strokes; Rectum inflammation; Autoimmune encephalitis; spotted white spots on the brain; Iron deficiency; Vitamin B deficiency; he felt off the bed; This spontaneous case was reported by a consumer and describes the occurrence of ENCEPHALITIS AUTOIMMUNE (Autoimmune encephalitis) and CEREBROVASCULAR ACCIDENT (It looked as he had strokes/Brain strokes) in a 43-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch nos. 045B21A and 039A21A) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below.     No Medical History information was reported.   On 30-Mar-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On 27-Apr-2021, received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) dosage was changed to 1 dosage form. In May 2021, the patient experienced IRON DEFICIENCY (Iron deficiency), VITAMIN B COMPLEX DEFICIENCY (Vitamin B deficiency) and FALL (he felt off the bed). In June 2021, the patient experienced CEREBROVASCULAR ACCIDENT (It looked as he had strokes/Brain strokes) (seriousness criteria hospitalization and medically significant). On 28-Jun-2021, the patient experienced CEREBRAL DISORDER (spotted white spots on the brain). In August 2021, the patient experienced ENCEPHALITIS AUTOIMMUNE (Autoimmune encephalitis) (seriousness criterion medically significant) and PROCTITIS (Rectum inflammation). The patient was hospitalized from sometime in June 2021 to sometime in July 2021 due to CEREBROVASCULAR ACCIDENT. The patient was treated with RITUXIMAB for Encephalitis autoimmune, at an unspecified dose and frequency and MYCOPHENOLATE MOFETIL (MYCOPHENOLATE) at an unspecified dose and frequency. At the time of the report, ENCEPHALITIS AUTOIMMUNE (Autoimmune encephalitis), CEREBROVASCULAR ACCIDENT (It looked as he had strokes/Brain strokes), IRON DEFICIENCY (Iron deficiency), VITAMIN B COMPLEX DEFICIENCY (Vitamin B deficiency), FALL (he felt off the bed) and CEREBRAL DISORDER (spotted white spots on the brain) outcome was unknown and PROCTITIS (Rectum inflammation) had resolved.      DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): In May 2021, Blood iron: low (Low) Iron deficiency. In May 2021, Vitamin B12: low (Low) Vitamin B deficiency. On 28-Jun-2021, Immunology test: high (High) They were really high. On 28-Jun-2021, Magnetic resonance imaging: abnormal (abnormal) spotted white spots on the brain. In August 2021, Immunology test: high immune levels were still high. On an unknown date, Magnetic resonance imaging: abnormal (abnormal) There are no changes on the imagen.         Caller reported that a week after 2 dose of Moderna vaccine patient started feeling stiffness of his left leg, he felt off the bed and started hitting himself on the walls. The week after he checked in with a doctor and they conducted laboratory tests including a vitamin test where they detected iron and vitamin B deficiency, and was advised to visit a neurologist. One week later, he started developing stiffness on his right leg. Physician carried out MRI after 4 week from 2 dose of vaccine but they were not sure if problem was with spinal cord that was causing these symptoms. By this time the patient had physical therapy 3 times a week and he could not even drive, in Jun 2021 his left hand also started failing. 20 Jun 2021 onwards patient was not able to work anymore and his right arm also started failing after he felt vertigo, by the end of June he was falling off with his entire body and was not able to walk without a cane or a stander walker. On 28 Jun patient again had MRI where they spotted white spots on the brain. It looked as he had strokes. Patient immune levels were really high so they thought it might be due to an infection, he was discharged on July 2021, they thought it was a stroke but could not find a cause for it and given cholesterol pill. During July symptoms got worse both hands and legs was not working, he was not able to walk and had to use support bars. By Aug 2021 his eyes were not alright and his learning ability either. On 5 Aug 2021 physician treated patient with plasma therapy and they noted a change on the stiffness, Patient was able to sit and his core was 50 percent in the right place, still patient was not able to walk but stiffness was better. Patient treated with plasma and physical therapy. On Aug and between Nov and Dec patient visited Surgeon for inflammation on the rectum. No Allergies. Patient had no COVID positive test or diagnosis.; Sender's Comments: This spontaneous case concerns a 43-year-old, male patient with no medical history reported who experienced the unexpected, serious (medically significant) adverse event of special interest of Encephalitis autoimmune and unexpected, serious (medically significant, hospitalization) adverse event of special interest of Cerebrovascular accident which occurred after the second dose of mRNA-1273. It was reported that patient initially experienced stiffness of the legs. He consulted a physician who requested for laboratory tests which revealed iron deficiency and vitamin B deficiency. He also consulted the emergency room where cranial MRI was done and showed spotted white spots on the brain. He was managed as a case of stroke and was given unspecified anti-cholesterol drug. His condition became progressive accompanied by symptoms of stiffness of the arms, vertigo, difficulty in ambulation, body weakness, eye problems, nystagmus, and ataxia. He became completely dependent on self-care. Three months after the initial clinical presentation he was diagnosed to have encephalitis autoimmune based on the finding of inflamed cerebellum from an unspecified imaging examination. He received plasma therapy which afforded improvement of stiffness. He was also started on Rituximab, Mycophenolate, and transfusions. The patient is also undergoing physical therapy. The benefit-risk relationship of mRNA-1273 is not affected by this report.