Age: 60.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Gait disturbance, Immediate post-injection reaction, Loss of personal independence in daily activities, Magnetic resonance imaging, Muscle spasms
Clinical narrative: Patient is still currently experiencing debilitating back spasms/pain; Patient is still currently experiencing debilitating back spasms/pain; one of the Doctor's thinks the vaccine attacked my central nervous system; I have been diagnosed with clonus by another doctor; I have been unable to do any of my normal activities for many months now; I can't even walk for a few minutes without debilitating pain; When I do walk I am hunched over and limp badly.; Now experiencing severe abdominal and Back spasms and left leg pain; Now experiencing severe abdominal and Back spasms and left leg pain; This is a spontaneous report received from contactable reporter(s) (Consumer or other non HCP). The reporter is the patient.  A 60 year-old male patient received bnt162b2 (BNT162B2), administered in arm left, administration date 22Apr2021 (Lot number: EW0182) at the age of 60 years as dose 1, single for covid-19 immunisation. The vaccine was administered in a Public Health Clinic/facility. The patient had no relevant medical history. Prior to vaccination the patient was not diagnosed with COVID-19 and has no known allergies. Concomitant medication(s) included: LEVOTHYROXINE. The patient did not receive any other vaccines within 4 weeks prior to the COVID vaccine.  The following information was reported: MUSCLE SPASMS (disability), BACK PAIN (disability) all with onset 01May2021, outcome "not recovered" and all described as "Patient is still currently experiencing debilitating back spasms/pain"; NERVOUS SYSTEM DISORDER (disability) with onset 01May2021, outcome "not recovered", described as "one of the Doctor's thinks the vaccine attacked my central nervous system"; CLONUS (disability) with onset 01May2021, outcome "not recovered", described as "I have been diagnosed with clonus by another doctor"; LOSS OF PERSONAL INDEPENDENCE IN DAILY ACTIVITIES (disability) with onset 01May2021, outcome "not recovered", described as "I have been unable to do any of my normal activities for many months now"; PAIN (disability) with onset 01May2021, outcome "not recovered", described as "I can't even walk for a few minutes without debilitating pain"; GAIT DISTURBANCE (disability) with onset 01May2021, outcome "not recovered", described as "When I do walk I am hunched over and limp badly."; ABDOMINAL RIGIDITY (disability), PAIN IN EXTREMITY (disability) all with onset 01May2021, outcome "not recovered" and all described as "Now experiencing severe abdominal and Back spasms and left leg pain". The events "patient is still currently experiencing debilitating back spasms/pain", "one of the doctor's thinks the vaccine attacked my central nervous system", "i have been diagnosed with clonus by another doctor", "i have been unable to do any of my normal activities for many months now", "i can't even walk for a few minutes without debilitating pain", "when i do walk i am hunched over and limp badly.", "now experiencing severe abdominal and back spasms and left leg pain" were evaluated at the physician office visit. The patient underwent the following laboratory tests and procedures: scan: inconclusive; investigation: inconclusive. The patient reported that treatment from pain management doctor has been ineffective and spine specialists doctors say that there was no structural damage to operate on. The patient will be seeing a neurologist on 22Jan2022 and reported that he was very close to being totally disabled. Therapeutic measures were taken as a result of muscle spasms, back pain, nervous system disorder, clonus, loss of personal independence in daily activities, pain, gait disturbance, abdominal rigidity, pain in extremity which included epidurals, steroid treatments, medial branch block. Since vaccination, the patient has not been tested for COVID-19. The patient received the second dose of BNT162B2 (lot number: EW0128), via an unspecified route of administration in the left arm on 17May2021 (at the age of 60 years old) as dose 2, single for COVID-19 immunisation.