Age: 64.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Thrombosis, Vaccination site pain, Weight bearing difficulty, X-ray
Clinical narrative: This is a spontaneous report from a contactable consumer (patient) and a physician. A 64-year-old female patient received BNT162B2 (PFIZER-BIONTECH COVID-19 MRNA VACCINE), dose 2 via an unspecified route of administration, administered in Arm Left on 09Apr2021 in the afternoon around 2 or 3 o clock (Batch/Lot Number: EW0153) as 2ND DOSE, SINGLE for covid-19 vaccination. The vaccination was done in her building, a medical team came to them. She lives in subsidized housing. The patient's medical history included tendonitis; juvenile idiopathic arthritis from Dec 1969 and ongoing; lupus nephritis from 1989 (diagnosed ten years after SLE); systemic lupus erythematosus (SLE) from Dec 1979; discoid lupus; proliferative kidney disease stage 3; sjogren's; raynaud's; arthritis (since she was 13); bursitis; oral necrosis (this was from being on a calcium drug that they give menopausal women, it was out of her head right now when reporting. She could not think of the name. The drug was supposed to promote bone growth and keep her from getting osteoporosis); menopausal (because of chemo she started menopause at 42); vulvar lichen sclerosus; filamentary keratosis from 2015 and ongoing (this was since either Feb 2015 or Mar 2015); kidney cysts(one is benign and one is being watched); liver hepatic hemangioma; allergies (Allergies to aspirin, penicillin, dextrose IV, Biaxin, Levaquin, Cipro, band-aid adhesive, zofran, sulfa topical. The sulfa is a topical as opposed to being the sulpha with a ph.); adeno conjunctivitis from Jan2015 and ongoing (she had a really bad case of this in JAN 2015 and had to quarantine for three weeks. She lost her vision, she could not see for three days. She got a fever. It left her with a filament thing. It is just delightful. It is viral and really bad. She got it at her eye doctors office when she was there for an annual visit. She sometimes had to go there 3 times to have filament growing on her eye scrubbed off. It is wicked painful. It is quite an adventure.); she used to be three quarters but she shrunk a little; has been a couch potato for a year, it comes with the territory with lockdown and being depressed; she is immunocompromised and catches many things and is high risk She feels like a sitting duck; had issues on her palm of hands; had issues on her breasts, and chest; and various problems. Family Medical History Relevant to adverse events was none.  No other vaccinations within four weeks prior to the first administration date of the suspect vaccine. No other vaccines administered on same date with the Pfizer vaccine considered as suspect. Concomitant medications included vitamin b complex (B-COMPLEX 100) 100 as dose did not clarify units, has been on for years; hydroxyzine embonate (HYDROXYZINE PAM) Dosage 25 mg, she did not remember indication, may be allergies, if she is around a cat, she takes it prophylactically; acetylsalicylic acid (ASPIRIN) low strength, 81 mg twice a week, has been on for decades, nephrologist put her on it in the 90's and She did not remember why, he said it preserves kidney function or it is good for overall health; pentoxifylline ongoing at 400 mg, 3 a day, she has been on for years, her vascular doctor prescribed; prednisone dosage:1 mg, she takes and alternates between 6 and 7 mg, If she takes lower than that, she is a "narcoleptic" (as reported, did not clarify); rosuvastatin Dosage:10 mg, frequency not specified, it is a nightly thing; fish oil (SUPER OMEGA 3) overall supplement that was suggested by former nephrologist at some point some; estradiol (YUVAFEM) Dosage:10 micrograms for menopause, vaginal dryness; there was no variable in her medication routine, she is on a long list of medications (she could not remember, one was blood pressure, with the last administration she was worked up and her blood pressure would not come down, she also takes Tylenol as needed), she provided the details as she knows them, but did not know full details for all of her medications. There was nothing new to her routine except like when Prilosec was taken off the market, she got a different medication for it. She has been on all of these for long term maintenance.  Historical vaccine included bnt162b2 (PFIZER-BIONTECH COVID-19 MRNA VACCINE), dose 1 via an unspecified route of administration, administered in Arm Left on 19MAR2021 (at the age of 64-year-old)(Batch/Lot Number: ER2613) for covid-19 vaccination, adverse events following prior vaccinations: none; and flu vaccine for immunization in last fall, 2020. She has a history of obscure side effects to medication, things that people have never heard of and she is the 1 in a million that has ever had these problems. The patient previously took ondansetron (ZOFRAN), ("a chemotherapy treatment", given before chemotherapy), which gave her a homicidal migraine and they had to give her ice packs for her head; 9 rounds of "Cytox" (Cytoxin or Cytoxan) she was not sure how this was spelled, and chemotherapy (9 rounds of chemo); azathioprine (IMURAN), she does not know if it was spelled Immuran or Imuran; prednisone a number of years and she said to her rheumatologist, "it did not make sense on an intellectual basis that the prednisone being effective in her body as it was once" and he said he would give her IMURAN which is given to kidney patients to cause less of a reaction with the organ, and patient mentioned she had barely an immune system after all these years on prednisone, she went through 3 rounds of steroids; Heparin IV, which  made her arm feel on fire on the inside, which they would not give her a flush when she had IV treatment; Dextrose IV made her skin feel hot and itchy, her mouth felt like she put something in that had been soaking in rubbing alcohol; ciprofloxacin (reported as "Cipro"), she had a bad reaction to Cipro, she was given after she was bit by a dog on her calves, she knew it was attached to and is "hurting her calves the rest of her life/the podiatrist said if it has not gone away, she is kind of stuck" (as reported, not specified). The patient just wanted to give Pfizer a full picture of what she was dealing with and she is an unusual case. She added that chemo was in the 90s and that is when all of the medication reactions she mentioned were. She absolutely does not have any of the information about the products she mentioned she had previous reactions to. Every time they did "this", it "hurt" and she asked them not to do it anymore. She asked them to not do dextrose anymore with the chemo because it feels like it is on fire, and she asked them to mix it with saline. She did not have any additional information, did not have the NDC, LOT, expiration date, or manufacturer for any of these medications she reported historical adverse events on. The patient reported that she got her 2nd shot of the Pfizer covid vaccine on 09Apr2021. She has soreness at the site, more-so several hours after getting the vaccine (09Apr2021). Just her arm felt sore within moments after the second vaccine, but she did not get this after the first. She rested and took it easy that weekend. There was Sore, Tired, general lethargy, and fatigue (Apr2021): when she looked online, it really only told her what everyone knows about that you might be sore and tired and she had all that, she thought she was through with all of that. She had no chills, just general lethargy and fatigue. She was sluggish and tired and not herself that weekend (Apr 2021). She stayed home so it is difficulty to say. Her arm was definitely sore. For sluggishness and fatigue, she said that she has been a couch potato for a year, it comes with the territory with lockdown and being depressed, so it is difficult to decide if it is health or physically induced or a emotional base. She did not knowingly spike a fever, no chills or sweats. And on Monday (did not clarify dates but states it was Monday after 09APR2021, throughout the weekend she took it easy), she noticed with her foot, she had difficulty getting out of bed could not put weight on her right foot. She was alarmed. She stayed home and rested and did a lot of napping and taking it slow. It is still difficulty and moving certain ways hurts more if she flexes. She has a known history of tendonitis so she wore her brace in the meantime. She thought maybe she had tendonitis in both ankles and this was similar so maybe it was a different set of tendons. She would wear a brace, and eventually it will get better in time. She also was wearing braces like compression socks that toes stick out of. She thought she had tendonitis and that is what she has done in the past. It has been a month and she is not better. This was her left foot, most of the pain was focused on the sole of her foot towards the outer edge. That is where it started. Then it migrated over time. That was weird and had her worried. It was all in her arch in the initial spot. She notes it is not like the tendonitis she had the first time. She does not want to be an alarmist or have her doctor think she is a hypochondriac she waited. She was then rubbing her foot, the right one, and noticed it was tender on the top of her foot just like the left one. There was sore. There was pain in right foot, pain in feet. Pain in feet, her left foot had most of the pain on the top and bottom and a lot of it is along the outer part of her sole of the foot. In her right foot, the pain is mostly at the fleshy part below her toes and on top of her foot. The pain moved around into the other foot for about a month so she went to the podiatrist yesterday (06May2021) and doctor did x-rays. The night before (05May2021), the opposite leg had a line of black and blue dots on her right calf that went up her leg, she did not notice this until Wednesday (05May2021) evening because she never examines it. She soaped up a washcloth and she knew where her parts are in the bath. Her mind wanders and she was not looking. She happened to be wearing something where her legs were not covered and that is how she knew. It did not hurt. It was strange, looking like bruising in a line. The doctor said it was all like one vein and he cold feel it. She can not feel it, but he could. The doctor told her these could be clots. She still has them. Doctor said the other leg where she had the pain was only soft tissue pain. Doctor found that every place that hurt when he touched it and it still hurts where he had touched it. She was told she does not have arthritis and she has had arthritis since she was 13. The doctor did not know what it is. It was her left foot constantly, and the right foot hurt off and on during that period. The left for sure was kind of a dull ache and throbbing. The right was only a little bit. The left was worse. It appeared to be soft tissue that was hurting and he said there are so many side effects of this new vaccine and to maybe try heat or ice. Ever since the patient left doctor's office until now (the time of reporting) she did not known if she need to be concerned, that if she does not know what it is, can ice or heat make it worse? She did not know the next steps. Treatment, she tried to keep it elevated because that can not hurt but that is about it. She has not done heat and ice because if the doctor does not know what it is, how does he know it will not make it worse. He asked if she could take aspirin and she said no she is allergic to aspirin. Tylenol she does not take often, only when she feels like she needs it and she has not been doing it often. When she stays off it, it does not hurt as much as when she is walking. She wanted  to know if she should be worried and she wanted to add (report this) to the database if this is a side effect and if Pfizer has ever heard of this before. There was also tired, general lethargy, and fatigue. At this point when reporting, she is single and lives alone, and said that "God forbid something happens, there is nobody to say let's get you to a hospital". She heard about blood clots on the news. When they said blood clot yesterday, it was a red warning light going on and a siren. At the time of reporting it was Friday and she did not know that if she need to rush to the hospital. Her primary care physician (PCP) said she had never heard of this and to call Pfizer. The patient asked if she is one of a small group of people this has happened to. She asked if she should not worry and it will go away or should she get to a hospital. She thought she had a problem with her feet (foot problem) but her podiatrist does not know what was going on. She communicated with her physician office today and she said she has never heard of this. She wanted to know if her symptoms have been heard of and if she should go to the hospital. The events did not require a visit to emergency room. The patient underwent lab tests and procedures which included: height as "5 and three quarters of an inch feet (5'0.75")" on an unspecified date; rapid COVID-19 test on 06May2021: negative; regular COVID-19 test on 06May2021: negative; x-ray on 06May2021 to make sure she did not break anything: unknown results. She also went because she had not done it in a year and she had something from the health department saying to get tested weekly for the virus (clarified that she was talking about the COVID tests as what she went and got done).  The outcome of the events was unknown.