Age: 70.0
Sex: F
Vaccine: COVID19
Symptoms: Anaphylactic reaction, Blood thyroid stimulating hormone, Fatigue, Pyrexia, Vaccination site rash
Clinical narrative: Severe allergic reactions, including anaphylaxis; 4 or 5 inches down from the injection site I have a rash, it's red, itchy...just yucky; Fever; Fatigue; This is a spontaneous report from a contactable consumer. A 70-years-old female patient received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE: Solution for injection; Batch/Lot number: unknown), via an unspecified route of administration (at the age of 70-years-old), administered in Arm Left on 25Feb2021 12:27 PM as dose 2, single for covid-19 immunisation. Medical history included herpes in her eye, osteoporosis from 2002, Blood pressure high from 2010, High cholesterol from 2010. Concomitant medication included valacyclovir hydrochloride (VALACYCLOVIR HYDROCHLORIDE) 1000mg a day taken for herpes ophthalmic and GABAPENTIN for unspecified indication. Historical vaccine included BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE: Solution for injection; Batch/Lot number: unknown), via an unspecified route of administration on 04Feb2021 at 10:58 AM for covid-19 immunisation. The patient said that she got her first dose 04Feb2021 at 10:58AM and second dose 25Feb2021 at 12:27PM, and both were given in her left arm. She said that her adverse effect was a reaction that has been continuing after second shot, which they gave her second shot in the same arm where the first was higher up. The patient also reported that "I am having a reaction to the second dose of the Pfizer covid vaccine. It's been going on for several days now. I was fine after the first shot. I got the second shot in the same arm as the first. About 4 or 5 inches down from the injection site I have a rash, it's red, itchy...just yucky. How long will these symptoms would last. She says that the next day she experienced a fever of 100.3, unable to verify if caller meant 100.3 degrees Fahrenheit. She says she had significant soreness under near her armpit, fatigue, and an itchy rash that is still current since 27th. She says that the rash started to appear she was initially sore around site with redness, and it started getting big and itchy. She says that the rash has stayed about the same. Caller says they have not had any other recent vaccinations or started any new medications. She says she does take Valacyclovir that she gets from Express Scripts that has an RX number on the pharmacy bottle label. She said she stopped taking this medication after her rash developed. Caller said she takes this medication for herpes in her eye, she has taken 1000mg a day for years. Caller said she also takes Gabapentin, no further details provided about this medication. Caller says that they get T4 levels, they are high, the day before she got the first dose, on 03Feb her TSH level or T4 was 4.94, which is above high normal and has been stable since they started monitoring it from way back in 2013. Patient reported Severe allergic reactions, including anaphylaxis, and other hypersensitivity reactions (for example rash, pruritus, urticaria, angioedema) have been reported following administration of the Pfizer-BioNTech COVID-19 Vaccine during mass vaccination outside of clinical trials. Provide that everyone may react differently. Caller said she applied Hydrocortisone cream yesterday, and she would have thought that maybe she should have had the second shot in her other arm. She said she had no symptoms after the first dose other than soreness and redness around injection site that went away within 2-3 days. The patient underwent lab tests and procedures which included blood thyroid stimulating hormone: 4.94 miu/l on 03Feb2021 TSH level or T4 was 4.94. The patient was treated with Hydrocortisone. No further details provided about the Hydrocortisone cream that she used. The outcome of the events was unknown.  No follow-up attempts are possible. Information about lot/batch number cannot be requested.