Sex: M
Vaccine: COVID19
Symptoms: Blood test, Discomfort, Phlebitis, Ultrasound Doppler, Ultrasound scan
Clinical narrative: it was uncomfortable for the patient; phlebitis in calf; This is a spontaneous report from a contactable physician. A 74-year-old male patient received second dose of bnt162b2 (BNT162B2 PFIZER-BIONTECH COVID-19 mRNA VACCINE, solution for injection, Batch/Lot number: UNKNOWN), via an unspecified route of administration on an unspecified date as dose 2, single for COVID-19 immunisation. The medical history of the patient included ongoing mild leukocytosis. The reporter reports that workup was negative and that the condition was ongoing. He said the patient had this condition for probably a few years now, chronic hepatitis c and was treated for it cured that was maybe 10 years ago, allergy to cipro it was unsure how long the patient had this allergy, allergy to sulfa reporter is not sure the reaction but guessed the reaction to sulfa is a rash. He was unsure how long the patient had this allergy, hypercholesterolaemia, hypertension, gastrooesophageal reflux disease, anxiety and migraine. The concomitant medications of the patient included atorvastatin (ATORVASTATIN) taken for hypercholesterolaemia, lisinopril (LISINOPRIL) taken for hypertension, omeprazole (OMEPRAZOLE) taken for gastrooesophageal reflux disease, lorazepam (ATIVAN) taken for anxiety and sumatriptan (SUMATRIPTAN). The patient previously received first dose of BNT162B2 on an unspecified date as single dose for COVID-19 immunisation. The prior Vaccinations within 4 weeks and AE(s) following prior vaccinations were reported as unknown. The investigation assessment was reported as yes. The Family Medical History Relevant to AE(s) was reported as unknown. The reporter said the phlebitis in calf began approximately 2 weeks ago from then. He said he talked with the patient precious day, he was markedly improved, there was no palpable core, it was not tender. The reporter said he has time for a report and that this patient was a consult on his case, he was not the patient primary care doctor, this patient had both doses of the Pfizer vaccine and said 4 weeks later the patient got phlebitis in his calf, he thought it was his right calf but said he was not sure. He said the patient was fine, that his primary care doctor gave him Eliquis, also known as apixaban and the signs of phlebitis had since dissipated. He said the onset of the phlebitis was a month after, so go back a month from his second dose, and 3 weeks before that was his first dose. Clarified he approximates the patient first dose to had been at the beginning of Feb2021 and the second dose to have been the end of Feb2021 or early Mar2021. He was not sure which arm the patient received either dose in but guessed in the right because the patient is a lefty. He said the patient was fine, he was physically active and had no other symptoms. For seriousness he said it was mildly disabling, not significant, it was uncomfortable for the patient, the patient was active. He said that was what they called unprovoked phlebitis. He said the patient platelets had not been tested, wanted him to get tested. He said he got some labs on him from previous encounters, he had a minor blood issue, clarified it was leukocytosis and elevated white blood count of unknown etiology. He had a whole host of lab studies (blood work), none of which were abnormal. He said he had asked the patient to get new labs, he had his prior labs, not recent. The patient got a duplex scan of the legs, that leg, an ultrasound but he did not have that result. He said the mild leukocytosis workup was over a year ago. He said he cannot find the patient recent labs, no date of process. The AE lead to Physician Office visit. The outcome of the event phlebitis in calf was reported as resolving and outcome of the event it was uncomfortable for the patient was reported as unknown.  No follow-up attempts are needed; information about lot/batch number cannot be obtained.