Age: 61.0
Sex: M
Vaccine: COVID19
Symptoms: Pain in extremity, Red blood cell sedimentation rate
Clinical narrative: He is also having pain in his forearm and shoulder; He is also having pain in his forearm and shoulder; It is up like then worse, its migrated from my shoulder up into my neck; I been having some other pains in other parts of my body; having pain in my forearm on the other side of my body/ Little excruciating pain; He is having some kind of autoimmune reaction the vaccine; frozen shoulder; This is a spontaneous report received from a contactable reporter(s) (Consumer or other non HCP) from medical information team, Program ID. The reporter is the patient.  A 61-year-old male patient received BNT162b2 (BNT162B2), on 15Jul2022 at 14:00 as dose 4 (booster), single (Lot number: FP7135) at the age of 61 years for covid-19 immunisation. The patient's relevant medical history included: "Arthritis" (unspecified if ongoing); "Allergy" (unspecified if ongoing); "Cholesterol" (unspecified if ongoing), notes: Indication for use in the case: Cholesterol. Concomitant medication(s) included: VALTRAX taken for hypersensitivity; ZOCOR taken for blood cholesterol; CELEBREX taken for arthritis. Vaccination history included: Covid-19 vaccine (DOSE 1, Single; Unknown Manufacturer), for COVID-19 IMMUNIZATION; Covid-19 vaccine (DOSE 2, Single; Unknown Manufacturer), for COVID-19 IMMUNIZATION; Covid-19 vaccine (DOSE 3 (BOOSTER), Single; Unknown Manufacturer), for COVID-19 IMMUNIZATION. The following information was reported: JOINT RANGE OF MOTION DECREASED (non-serious) with onset 17Jul2022, outcome "not recovered", described as "frozen shoulder"; AUTOIMMUNE DISORDER (medically significant), outcome "unknown", described as "He is having some kind of autoimmune reaction the vaccine"; PAIN IN EXTREMITY (non-serious), ARTHRALGIA (non-serious), outcome "not recovered" and all described as "He is also having pain in his forearm and shoulder"; NECK PAIN (non-serious), outcome "not recovered", described as "It is up like then worse, its migrated from my shoulder up into my neck"; PAIN (non-serious), outcome "unknown", described as "I been having some other pains in other parts of my body; having pain in my forearm on the other side of my body/ Little excruciating pain". The patient underwent the following laboratory tests and procedures: Red blood cell sedimentation rate: (28Mar2023) Normal, notes: I did you know I had a curiosity I had to check my SED rate and it come back you know, normal. Therapeutic measures were taken as a result of joint range of motion decreased, pain in extremity, arthralgia, neck pain. Therapeutic measures were not taken as a result of pain. Clinical course: It was reported that the patient had been told by his physician that he had autoimmune response to his last Covid booster shot. It has resulted in a frozen shoulder which has no persisted for nine. It was further stated that the patient was calling regarding the Pfizer COVID 19 booster dose and patient received Gray cap, Original (Monovalent), greater than equal to 12 years - 30 mcg/dose, Do not dilute. He received the booster shot around 15Jul2022 and he was having an issue with the shoulder since then. He went to his doctor and the doctor said that the shoulder was frozen. He was having some kind of autoimmune reaction the vaccine. The pain was still persisting. He was also having pain in his forearm and shoulder that is still persisting. He was taking physical therapy for the pain. He was wondering what he should do next for it. Caller added that he had his vaccination card with him, it mentions: 15Jul2022 and stated that it was different than the injection site, cause it was systemic and mentioned that when he went and saw doctor initially, he meant this was the last thing he expected to hear from him, was that he had an immune response to the vaccine. It was a surprise and given that it's persisted. The patient further stated that, he had been having some ongoing issues with his shoulder. It occurred immediately after giving last booster shot for the COVID-19 vaccine, and he went to his doctor after a couple of weeks, and he said that his shoulder was frozen and it because he have had an auto-immune reaction to the vaccine and his body was producing collagen which was freezing up his shoulder. When confirmed that patient was not sure that this pain in body is related to vaccine. He also stated that the shoulder happens to mediate it was like within a day but now he was having pain in his forearm on the other side of his body and that's only happened in last couple of weeks. The consumer stated that he thought it was about 2 weeks ago and they are just a little excruciating pain. When confirmed that consumer still experiencing the pain, consumer stated that it comes and goes a little bit not less than like it was about, so there was 3 or 4 episodes where it was so bad you had to stop whatever you were doing and now, he was feeling in the same location the pain but it's not as bad. When probed for treatment, consumer stated that he had not done anything for it now, he wanted to see his doctor and he was going to diagnose it, he was an orthopedic surgeon and he prescribed some physical therapy and so, he was been doing exercises which were just motion exercises, tried to keep that moves and he continued to do those, but they did not seem to have any effect on it. It was not constant but it's extremely regular, it's almost every day that he experienced it and if anything, it's probably little bit worst now. He thought they were like nine months now after the vaccination. When confirmed that pain is worsened, consumer stated, "It was up like then worse, its migrated from his shoulder up into his neck. It sometimes at night it wakes him up if he was sleeping on that side because its hurts. The patient also stated that he had been having some other pains in other parts of his body, having pain in his forearm on the other side of his body. The patient had not taken any vaccine 4 weeks prior to Pfizer COVID-19 vaccine. The patient did not take any Pfizer vaccine on same day. Other Products: Yes.