Sex: M
Vaccine: COVID19
Symptoms: CSF white blood cell count, Carbon dioxide, Chest X-ray, Computerised tomogram, Double stranded DNA antibody
Clinical narrative: tested positive on a routine screening for COVID-19; tested positive on a routine screening for COVID-19; This is a literature report.  A 45-year-old male patient received BNT162b2 (BNT162B2), in May2021 as dose 1, single (Batch/Lot number: unknown) and in May2021 as dose 2, single (Batch/Lot number: unknown) for covid-19 immunisation. The patient's relevant medical history included: "He had previously fractured his lumbar spine" (unspecified if ongoing); "which led to lower extremity weakness and numbness" (unspecified if ongoing); "which led to lower extremity weakness and numbness" (unspecified if ongoing); "dependent on a cane" (unspecified if ongoing); "feet had gradually become deformed" (unspecified if ongoing); "tendon destruction" (unspecified if ongoing), notes: tendon and bony destruction in both ankles; "bony destruction" (unspecified if ongoing), notes: tendon and bony destruction in both ankles; "wear braces on both ankles" (unspecified if ongoing); "repetitive abscesses in his ankles" (unspecified if ongoing); "history of heavy alcohol drinking", stop date: Jun2021; "asthma" (unspecified if ongoing); "hospitalization", start date: 1999 (unspecified if ongoing), notes: his first psychiatric hospitalization was in 1999 after his father committed suicide; "disability", start date: 2000 (unspecified if ongoing); "motor vehicle accident", start date: 2000 (unspecified if ongoing); "back injury" (unspecified if ongoing); "previous suicide attempt by hanging himself" (unspecified if ongoing). The patient's family history included: "his father committed suicide" (unspecified if ongoing). The patient's concomitant medications were not reported. Past drug history included: Mirtazapine for Psychotropic, notes: 7.5mg at bedtime; Risperidone for Psychotropic, notes: 1mg in the morning and 3mg at bedtime; Lithium for bipolar disorder, notes: bipolar disorder in his late teens; Hydroxyzine for agitation; Benadryl for agitation, reaction(s): "Drug ineffective"; Carbamazepine for agitation, reaction(s): "Drug ineffective"; Olanzapine for agitation, reaction(s): "Drug ineffective"; Clonazepam for agitation, reaction(s): "Drug ineffective"; Thiamine for Wernicke Korsakoff syndrome; Lorazepam for catatonia; Escitalopram. The following information was reported: VACCINATION FAILURE (medically significant), COVID-19 (medically significant) all with onset 06Jan2022, outcome "recovered" (17Jan2022) and all described as "tested positive on a routine screening for COVID-19". The patient underwent the following laboratory tests and procedures: Alanine aminotransferase (0-49): (unspecified date) 26, notes: units/L; Angiogram: (unspecified date) rule out a pulmonary embolism; (unspecified date) No acute intracranial abnormalities. No evidence o, notes: of vessel wall enhancement of the intracranial arteries; Anion gap (4-16): (unspecified date) 8; Anti-neuronal antibody: (unspecified date) negative; Anti-neuronal antibody (normal high range 1:10): (unspecified date) less than 1:10; Anti-NMDA antibody (normal high range 1:1): (unspecified date) less than 1:1; Anti-thyroid antibody (0.0-9.0): (unspecified date) 3.9 IU/ml; Aspartate aminotransferase (17-59): (unspecified date) 50, notes: units/L; Bacterial test: (Aug2021) unknown result; Blood 25-hydroxycholecalciferol: (unspecified date) less than 4; Blood albumin (3.5-5.2): (unspecified date) 3.7 g/dl; Blood alkaline phosphatase (38-126): (unspecified date) 63, notes: units/L; Blood bilirubin (0.3-1.2): (unspecified date) less than 0.1, notes: low; Blood calcium (8.6-10.2): (unspecified date) 9.4 mg/dl; Blood chloride (98-107): (unspecified date) 102 mmol/L; Blood cholesterol (normal high range 200): (unspecified date) 166 mg/dl; Blood creatine phosphokinase (55-170): (unspecified date) 704, notes: units/L; Blood creatinine (0.66-1.25): (unspecified date) 0.75 mg/dl; Blood folate (normal low range 4.0): (unspecified date) 2.3 ng/ml, notes: Low; Blood glucose (70-99): (unspecified date) 79 mg/dl; Blood magnesium (1.6-2.6): (unspecified date) 2.0 mg/dl; Blood phosphorus (2.5-4.5): (unspecified date) 3.6 mg/dl; Blood potassium (3.5-5.1): (unspecified date) 3.9 mmol/L; Blood sodium (136-145): (unspecified date) 140 mmol/L; Blood thyroid stimulating hormone (0.47-4.68): (unspecified date) 0.69 MiU/L; Blood triglycerides (normal high range 150): (unspecified date) 139 mg/dl; Blood urea (9-20): (unspecified date) 19 mg/dl; Body mass index: (unspecified date) 19.5, notes: within normal range; Carbon dioxide (21-30): (unspecified date) 31 mmol/L, notes: High; Chest X-ray: (10Jan2022) showed opacities in the mid and lower lung zones b, notes: bilaterally, perhaps due to multifocal pneumonia; Computerised tomogram: (07Jun2021) showed cellulitis and abscess on the lateral right, notes: ankle with destruction of cartilage, widening of the joint space, and multiple bony fragments; C-reactive protein (normal high range 1.0): (unspecified date) 6.3 mg/dl; CSF cell count: (unspecified date) 0 %; CSF culture: (unspecified date) negative, notes: w Gram Stain; CSF glucose (40-70): (unspecified date) 71 mg/dl; CSF lymphocyte count: (unspecified date) 100 %; CSF protein: (unspecified date) negative, notes: 14-3-3 protein; CSF protein: (unspecified date) less than 0.2, notes: 14-3-3 Tau-prion disease; CSF protein (0-1149): (unspecified date) 127 pg/mL, notes: T-tau protein; CSF protein (12-60): (unspecified date) 19 mg/dl; CSF red blood cell count (0-0): (unspecified date) 3, notes: High unit: /mcL; CSF white blood cell count (0-5): (unspecified date) 0, notes: /mcL; Double stranded DNA antibody (0-24): (unspecified date) 3; Drug level (4.0-12.0): (unspecified date) 8.0, notes: mcg/mL; Drug level: (Aug2021) normal, notes: back negative; Electroencephalogram: (unspecified date) This is a normal EEG. No epileptiform discharges a, notes: are seen. Clinical correlation: A normal EEG does not rule out the diagnosis of epilepsy. Clinical correlation is recommended; Fibrin D dimer: (unspecified date) within normal limits; Haematocrit (37.0-50.0): (unspecified date) 39.4 %; Haemoglobin (12.6-17.4): (unspecified date) 13.0 g/dl; Haemoglobin (normal high range 5.6): (unspecified date) 5.7 %, notes: High; Hepatitis A antibody: (unspecified date) negative; Hepatitis B core antibody: (unspecified date) negative; Hepatitis B surface antigen: (unspecified date) negative; Hepatitis C antibody: (unspecified date) negative, notes: Interp; High density lipoprotein (normal low range 60): (unspecified date) 34 mg/dl; HIV antibody: (unspecified date) nonreactive, notes: nonreactive; ANA, HEp2, IgG (normal high range 1:80): (unspecified date) 1:80; Autoimmune markers: (Aug2021) were investigated; (unspecified date) N/A; (unspecified date) N/A; (unspecified date) Clear; (unspecified date) Colorless; (Aug2021) were ordered to rule out underlying neurologic and, notes: autoimmune illnesses; (unspecified date) Non detected; (unspecified date) Negative; (unspecified date) negative; SSA 52 (Ro) (ENA), IgG (0-40): (unspecified date) 2, notes: AU/mL; (unspecified date) 2, notes: AU/mL; (unspecified date) 0, notes: AU/mL; (unspecified date) non reactive, notes: non reactive; Laboratory testing: (unspecified date) revealed that the patient's d-dimer was within normal, notes: limits; (03Aug2021) was largely unremarkable, except for a urinalysis, notes: which indicated a possible urinary tract infection (UTI); Low density lipoprotein (normal high range 100): (unspecified date) 104 mg/dl; Lumbar puncture: (Aug2021) unknown results; Magnetic resonance imaging head: (Aug2021) No acute intracranial abnormalities, notes: No evidence of vessel wall enhancement of the intracranial arteries. Findings: No evidence of acute intracranial hemorrhage or infarction. No evidence of hydrocephalus Moderate nonspecific confluent T2 hyperintensity in the periventricular white matter of both cerebral  hemispheres No abnormal enhancement in the brain parenchyma or leptomeninges Intracranial arteries are patent. No evidence of aneurysms.No abnormal enhancement in vessel walls; Mean cell haemoglobin (28.0-33.0): (unspecified date) 31.2 pg; Mean cell haemoglobin concentration (33.0-36.0): (unspecified date) 33.0 g/dl; Mean cell volume (80.0-96.0): (unspecified date) 94.5, notes: fL; Mean platelet volume (9.4-12.4): (unspecified date) 10.7, notes: fL; Neurological examination: (Aug2021) unknown results; Oxygen saturation: (unspecified date) above 94% on room air; (10Jan2022) 92 and 94, notes: fluctuating between; Platelet count (153-367): (unspecified date) 285, notes: K/mcL; Polymerase chain reaction: (unspecified date) Not detected, notes: LYME DNA; Positron emission tomogram: (unspecified date) FDG PET/CT imaging of the brain shows relative dec, notes: decrease in metabolic activity in bilateral occipital, left inferior area of temporal lobe, and cerebellum bilaterally compared to the normal radiotracer distribution in the bilateral cerebral hemispheres. These findings are non-specific and clinic correlation is recommended; Protein total (6.3-8.2): (unspecified date) 6.5 g/dl; Red blood cell count (4.00-5.70): (unspecified date) 4.17, notes: M/mcL; Red blood cell scan: (unspecified date) 0.0 %, notes: Nucleated; Red blood cell scan: (unspecified date) 0.0, notes: Nucleated -K/mcL; Red blood cell sedimentation rate (0-15): (unspecified date) 39, notes: mm/hour; Red cell distribution width (12.0-15.2): (unspecified date) 13.2 %; SARS-CoV-2 test: (06Jan2022) tested positive; Thyroxine free (0.6-2.5): (unspecified date) 1.1 ng/dL; Treponema test: (unspecified date) nonreactive, notes: T Pallidum Ab; (unspecified date) nonreactive; Urine analysis: (unspecified date) indicated a possible urinary tract infection (UTI); Vitamin B1 (70-180): (unspecified date) 308 nmol/L; Vitamin B12 (239-931): (unspecified date) 419 pg/mL; Vitamin D (20-80): (unspecified date) 36 ng/ml; Vitamin D: (unspecified date) 36 ng/ml; White blood cell count (4.5-11.0): (unspecified date) 8.8, notes: K/mcL; White blood cell count: (07Jun2021) mild elevation. Therapeutic measures were taken as a result of vaccination failure, covid-19.; Sender's Comments: Based on the current available information and the plausible drug-event temporal association, a possible contributory role of the suspect product BNT162B2 to the development of the reported events cannot be totally excluded.