Age: 70.0
Sex: M
Vaccine: COVID19
Symptoms: Balance disorder, Dyspnoea, Fatigue, Gait disturbance, Impaired work ability
Clinical narrative: Lost 50 Lbs. after 2nd shot; Balance issues after 2nd shot; Could not even open a water bottle after 2nd shot; Muscle loss after 2nd shot; Muscle weakness after 2nd shot; Tired after 2nd shot; Could barely walk after 2nd shot/Can not walk on unsmooth surfaces; Gasping for air after 2nd shot; Has not been able to work; This spontaneous case was reported by a consumer and describes the occurrence of GAIT DISTURBANCE (Could barely walk after 2nd shot/Can not walk on unsmooth surfaces), BALANCE DISORDER (Balance issues after 2nd shot), DYSPNOEA (Gasping for air after 2nd shot), LOSS OF PERSONAL INDEPENDENCE IN DAILY ACTIVITIES (Could not even open a water bottle after 2nd shot) and WEIGHT DECREASED (Lost 50 Lbs. after 2nd shot) in a 70-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch nos. 013A21A and 004M20A) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below.     Concurrent medical conditions included AFib (he was diagnosed with A-Fib before second dose.).   On 27-Jan-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On 26-Feb-2021, received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) dosage was changed to 1 dosage form. On 26-Feb-2021,  after starting mRNA-1273 (Moderna COVID-19 Vaccine), the patient experienced IMPAIRED WORK ABILITY (Has not been able to work). In March 2021, the patient experienced GAIT DISTURBANCE (Could barely walk after 2nd shot/Can not walk on unsmooth surfaces), DYSPNOEA (Gasping for air after 2nd shot) and FATIGUE (Tired after 2nd shot). In May 2021, the patient experienced LOSS OF PERSONAL INDEPENDENCE IN DAILY ACTIVITIES (Could not even open a water bottle after 2nd shot). May 2021, the patient experienced MUSCLE DISCOMFORT (Muscle loss after 2nd shot) and MUSCULAR WEAKNESS (Muscle weakness after 2nd shot). On 01-Nov-2021, the patient experienced BALANCE DISORDER (Balance issues after 2nd shot). On 29-Nov-2021, the patient experienced WEIGHT DECREASED (Lost 50 Lbs. after 2nd shot). At the time of the report, GAIT DISTURBANCE (Could barely walk after 2nd shot/Can not walk on unsmooth surfaces) and BALANCE DISORDER (Balance issues after 2nd shot) had not resolved and DYSPNOEA (Gasping for air after 2nd shot), LOSS OF PERSONAL INDEPENDENCE IN DAILY ACTIVITIES (Could not even open a water bottle after 2nd shot), WEIGHT DECREASED (Lost 50 Lbs. after 2nd shot), IMPAIRED WORK ABILITY (Has not been able to work), MUSCLE DISCOMFORT (Muscle loss after 2nd shot), MUSCULAR WEAKNESS (Muscle weakness after 2nd shot) and FATIGUE (Tired after 2nd shot) outcome was unknown.      DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On 29-Nov-2021, Physical examination: decreased (Low) weight loss. Lost 50 lbs..         No Concomitant product use was reported. No treatment information was provided.  Patient reported that right before the 2nd shot, his feet were swollen. Visited ER, and he was diagnosed with Atrial fibrillation and kept him in the hospital for 3 days. The lung doctor stated that there was nothing wrong with the lungs and advised the patient to take to a neurologist. In May-2021 they finally visited the neurologist and was diagnosed with Muscle loss and weakness. The patient could not even open a water bottle. Two weeks later, the patient was feeling better and breathing better too. The patient lost 50 Lbs. and still had balance issues and was not able to walk on unsmooth surfaces. It took 6 months for them to recover and feel better. The patient used to work, and this had put a financial strain because they used to work and was no longer able to work.   This case was linked to MOD-2021-399978 (Patient Link).