Age: 50.0
Sex: M
Vaccine: COVID19
Symptoms: Haemoglobin, SARS-CoV-2 test, White blood cell count
Clinical narrative: diagnosed with COVID19 after receiving vaccine/ patient tested positive for COVID on 19Apr2021/ was asymptomatic; diagnosed with COVID19 after receiving vaccine/ patient tested positive for COVID on 19Apr2021/ was asymptomatic; This is a spontaneous report from a contactable pharmacist. A 50-year-old male patient received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, solution for injection), via an unspecified route of administration on 01Apr2021 (Batch/Lot Number: ER8737; Expiration Date: 31Jul2021) as single dose (first dose) (at the age of 50 years old) and via an unspecified route of administration on 19Apr2021 (Batch/Lot Number: ER8731; Expiration Date: 31Jul2021) as single dose (second dose), for COVID-19 immunisation. Medical history included traumatic brain injury from 13Mar2021, alcohol abuse, pseudomonas pneumonia, pain, bowel dysfunction, sleep disorder and mood disorder, neuropathic pain, seborrhoeic dermatitis, obesity and increased alertness. Concomitant medications included paracetamol (ACETAMINOPHEN) taken for pain relief; docusate taken for bowel management from 05Apr2021 and ongoing; enoxaparin injection taken for DVT prophylaxis from 30Mar2021 and ongoing; gabapentin taken for neuropathic pain from 30Mar2021 and ongoing; methylphenidate taken for increased alertness (unknown dose from 30Mar2021; Patient takes 10 mg twice a day and it was started on 08Apr2021; it was initially 2.5 mg on 03Apr2021 and then increased to 5 mg on 07Apr2021. The dose was then increased to 10 mg on 08Apr2021 and the patient is currently on 10 mg.  This is a normal dosing schedule and due to a typical dose increase. The increase in dose was not due to effectiveness, but because of how the medication is started.); macrogol 3350 (MIRALAX) taken for bowel management from 30Mar2021 and ongoing; senna alexandrina leaf (SENNA [SENNA ALEXANDRINA LEAF]) taken for bowel management from 06Apr2021 and ongoing; trazodone taken for sleep and mood  from 31Mar2021 and ongoing; and pimecrolimus (ELIDEL cream) taken for seborrhoeic dermatitis from 13Apr2021 and ongoing. The patient previously took cipro [ciprofloxacin] for pseudomonas pneumonia (completed cipro on 31Mar2021). The patient received Diphtheria Pertussis Tetanus (DPT) vaccine on 13Mar2021. On 19Apr2021, the patient experienced diagnosed with COVID19 after receiving vaccine. The patient tested positive for COVID on 19Apr2021. The patient was hospitalized at the time of diagnosis. The pharmacist clarified that the patient had been hospitalized prior to receiving the COVID-19 vaccines and prior to being diagnosed with COVID-19. The patient was not admitted to an Intensive Care Unit. The patient was still hospitalized. The patient did not display clinical signs at rest indicative of severe systemic illness and patient is currently asymptomatic. The patient did not require supplemental oxygen (including high flow or ECMO) or receive mechanical ventilation. The facility was assuming he had exposure but they do not know where the exposure came from or the origin. The patient is on acetaminophen but it is scheduled and he has no documented fever. No new or worsened symptoms/signs during the COVID-19 illness experienced (Multiorgan failure, Respiratory, Cardiovascular, Gastrointestinal/Hepatic, Vascular, Renal, Neurological, Hematological. Dermatological, Other: none). The patient did not receive any additional therapies (event did not require the initiation of new medication or other treatment or procedure) for COVID-19. The patient been treated with immunomodulating or immunosuppressing medications or received any other vaccines around the time of COVID-19 vaccination: the elidel cream, which is a very small amount and applied topically. The patient received his first dose on 01Apr2021. Patient received his second dose yesterday on 19Apr2021. Between the time the patient was administered the vaccine, he also was given a COVID test for placement purposes. The patient tested positive for COVID, and was asymptomatic. The facility that the patient is being transferred to has requested that the pharmacist call to confirm that the patient does not need another dose of the vaccine. The pharmacist confirmed that the patient tested positive for COVID-19 on 19Apr2021. No other vaccines administered on same date with the Pfizer vaccine considered as suspect. The patient underwent lab tests and procedures on 19Apr2021 which included Serum creatinine: 1.04 (normal kidney functioning), CBC: unknown results, Hematocrit: 36.6, Hemoglobin: 12.2 and white blood cells: 5.3; and the patient had an (Unspecified, NAA ICU for the type of COVID test, as reported) COVID19 test with following results: negative on 13Mar2021, negative on 23Mar2021, negative on 26Mar2021 and positive on 19Apr2021. The outcome of the events was unknown.; Sender's Comments: A possible contributory effect of suspect BNT162B2  on reported events cannot be excluded in a context of LOE.