Age: 68.0
Sex: M
Vaccine: COVID19
Symptoms: Back pain, Cholecystectomy, Condition aggravated, Fatigue, Ultrasound scan
Clinical narrative: At that time, was 192 pounds, lost some since then because caller had gallbladder removed; Gallbladder removed on 07Apr2022, no caller clarifies it was 24Mar2022; had pain in his very low back, started hurting, starting progressing and getting worse each day, a tad worse, a tad worse; had pain in his very low back, started hurting, starting progressing and getting worse each day, a tad worse, a tad worse; got a real tired feeling in his legs that night; This is a spontaneous report received from contactable reporter(s) (Consumer or other non HCP and Physician) from medical information team. The reporter is the patient.  A 68-year-old male patient received BNT162b2 (BNT162B2), on 25Oct2021 as dose 3 (booster), single (Lot number: FC3184) at the age of 68 years, in left arm for covid-19 immunisation. The patient's relevant medical history included: "tad of arthritis in his back" (unspecified if ongoing). There were no concomitant medications. Vaccination history included: BNT162b2 (Pfizer COVID-19 vaccine, 1st dose:, Date: 16Mar2021, NDC number: unknown, Lot number, expiration date: EP7534, believes that is the expiration date, Dose, route: unknown, took the normal first dose), administration date: 16Mar2021, when the patient was 68-year-old, for Covid-19 immunization; BNT162b2 (Pfizer COVID-19 vaccine, 2nd dose:, Date: 06Apr2021, NDC number: unknown, Lot number: EW0153, Expiration date: unknown), administration date: 06Apr2021, when the patient was 68-year-old, for COVID-19 Immunization. The following information was reported: FATIGUE (non-serious) with onset 25Oct2021, outcome "recovered" (26Oct2021), described as "got a real tired feeling in his legs that night"; BACK PAIN (non-serious), CONDITION AGGRAVATED (non-serious) all with onset 27Oct2021, outcome "recovered" (23Dec2021) and all described as "had pain in his very low back, started hurting, starting progressing and getting worse each day, a tad worse, a tad worse"; CHOLECYSTECTOMY (non-serious) with onset 24Mar2022, outcome "unknown", described as "Gallbladder removed on 07Apr2022, no caller clarifies it was 24Mar2022"; WEIGHT DECREASED (non-serious), outcome "unknown", described as "At that time, was 192 pounds, lost some since then because caller had gallbladder removed". Relevant laboratory tests and procedures are available in the appropriate section. Therapeutic measures were taken as a result of back pain, condition aggravated, fatigue.  Additional information: 68 year old male patient received his third dose of the Pfizer COVID-19 vaccine (Adult) end of October2021. Two days after he had lower back pain and is wanting to know if it could be related to the vaccine because he is wanting to receive his fourth dose. Consumer stated that the pain started on 27Oct2021 and got progressively worse to the point of severe as far as sitting and bending and then just went away with no therapy. Consumer added "he suffered for over a month and a half with it, he never had back pain like that before, sometimes he gets a very little arthritis and every now and then it will flare up but after a couple days with just rest it goes away. He have never had anything like this before. Consumer also stated that he consulted his HCP and they couldn't narrow it down " they were some suggestions like a pinched nerve, or infected nerve, but by the time I went to the spinal person, it had all cleared up, this was cleared up on Christmas eve and his appt with the spine doctor was the following week so he went there with no symptoms. Although he did have a recent back x-ray from 1nov2021 and he had seen nothing there. He had no suggestions. He agreed that arthritis would not last like that every day and get progressively worse. He never went through anything like that in his life, he didn't strain his back and had no fall everything was normal. It's just started and started getting worse and worse. Christmas eve, when he had to go to bed his legs felt tired like ran a long way, real tired feeling in both of his legs and woke Christmas morning and everything was gone. Something caused it and thet don't know what it was, nothing showed up on the x-ray. The only thing different he did was getting the shot. The consumer asked how long did muscle pain normally last with the Pfizer COVID-19 Vaccine. Are there any problems with the people getting their fourth shot of the Pfizer COVID-19 vaccine? Was everything going alright with that? Are the reactions with the fourth the same that with the first three doses? Consumer had his Pfizer COVID-19 vaccine booster in the end of Oct2021. He had the first two shots and then got the booster Oct2021. Now he was up for the 2nd booster according to the doctor. Consumer had a question because he went through something two days after he got the booster in Oct2021. Consumer has always had a tad of arthritis in his back. Didn't fall or pull his back, wasn't ill or sick, but two days after he got the booster shot caller had pain in his very low back, started hurting, starting progressing and getting worse each day, a tad worse, a tad worse. Two weeks before Christmas still had the pain and had to sit on one of those donuts. This pain was a pain he never had before in his back. The pain lasted the rest of October, all of November and then right up until Christmas eve, and then the pain just disappeared. Was that pain a reaction to the booster? Not saying it is the booster, just the timing of the thing and not being anything else like a fall or stretch or pull or illness. Consumer confirmed the booster dose he was calling about was his 3rd dose, which he got 25Oct2021, and the pain started 2 to 3 days after that shot. Then the pain went away, funny, before the pain went away he got a real tired feeling in his legs that night, then woke up and everything was perfect. Had a couple of procedures going on at the time, he ran this by the doctors, the pain that was going on with him. Had a referral to go to pain management to help with the pain. That appointment would have been a week after Christmas. Doctor caller ran into suggested it could be a pinched nerve or infected nerve. A week after Christmas caller had an appointment with pain management because the pain was so great. Consumer also mentioned he couldn't stay on the Aleve because the Aleve was upsetting his stomach. The Aleve wasn't helping, making him sick. Pain was an indicator not to do something, if you are doing something and getting pain that tells you what not to do. He took Extra Strength Tylenol. The last few days the doctor told caller to stick to the two Aleve, after the 3rd day of the regimen caller's stomach was shot. He has a very little, tad, of arthritis, which is absolutely great for his age. When he did have flare ups with his back nothing lasted more than 2 or 3 days, nothing as severe as this back pain was. Gallbladder was removed on 07Apr2022, he clarified it was on 24Mar2022, it's an old guy thing. If consumer needs to get the 4th dose, the booster, he wants to get it. He was really curious about this back thing. Patient weight at that time, was 192 pounds, lost some since then because he had gallbladder removed. He was in his second week of recovery now. Now his weight was 186 pounds. Time the vaccination was given was early in the morning about 8:30AM or 9AM. No additional vaccines were administered on same date of the Pfizer suspect. The AE did not require a visit to emergency room or physician office because he had an upcoming doctor visit, was trying to hold off from regular primary physician, did tell him to come in and see an associate because the pain was so bad 3 days before Christmas, she's the one that put him on the round the clock regimen of Aleve. Called back to get a referral to see the pain management group. Her theory was well he was just old, no exam or anything like that. No vaccinations within four weeks prior to the first administration date of the suspect vaccine(s) was administered. The patient had no family medical history relevant to AE(s). There were no AE(s) following prior vaccinations. Relevant Tests included they did do a series of x-rays on consumer 's back, not for the pain, a checkup because in their mind he shouldn't have lost as much weight as he did at that time. That's how they found the gallbladder problem because they did a series of checks. Pain management doctor was there and saw him. At that time the primary doctors concern was caller lost 10 pounds in 3 months, and had an ultrasound that indicated the gallbladder. X-ray of the back in Nov2021 for a checkup to see the cause of caller losing weight. Pain cleared up Christmas Eve. Legs got numb like caller ran 50 miles, next morning it was gone. He follows along with a spine doctor and pain management doctor. Doctor was amazed at how well he does with his age.  No follow-up attempts are possible. No further information is expected.