Age: 69.0
Sex: F
Vaccine: COVID19
Symptoms: Angiogram pulmonary, Blood pressure measurement, Cough, Dyspnoea, Gait inability
Clinical narrative: This spontaneous case was reported by a physician and describes the occurrence of DYSPNOEA (Difficulty breathing/I also felt somewhat breathless o the stairs), RESPIRATORY RATE INCREASED (Respirations >20 per min), GAIT INABILITY (I could hardly walk upstairs) and COUGH (Dry cough that dissipated over several weeks) in a 69-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch nos. 042L20A and 037K20A) for COVID-19 vaccination.  The patient's past medical history included Anaphylaxis. Concurrent medical conditions included Clotting disorder (prothrombin abnormality, clotting disorder) since 1999, Hernia (Small hiatal hernia) since 2018 and Hypertension (BP was increasing for a few months before, in 2020) since 2000. Concomitant products included OMEPRAZOLE for Heartburn, HYDROCHLOROTHIAZIDE and AMLODIPINE for Hypertension. On 02-Jan-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 26-Jan-2021, received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) dosage was changed to 1 dosage form. On 01-Apr-2021, the patient experienced DYSPNOEA (Difficulty breathing/I also felt somewhat breathless o the stairs) and RESPIRATORY RATE INCREASED (Respirations >20 per min). On an unknown date, the patient experienced GAIT INABILITY (I could hardly walk upstairs) and COUGH (Dry cough that dissipated over several weeks). The patient was treated with ALBUTEROL [SALBUTAMOL] for Adverse event, at an unspecified dose and frequency. At the time of the report, DYSPNOEA (Difficulty breathing/I also felt somewhat breathless o the stairs) and RESPIRATORY RATE INCREASED (Respirations >20 per min) had resolved with sequelae, GAIT INABILITY (I could hardly walk upstairs) outcome was unknown and COUGH (Dry cough that dissipated over several weeks) had resolved.   DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available):On an unknown date, Angiogram pulmonary: negative (Negative) PE, COVID and perocardiis ruled out by pulmonay angiogram. On an unknown date, Blood pressure measurement: high (High) Blood pressure was high. On an unknown date, Pulmonary function test: normal percent (normal) PFTs showed reduced FEV and FEV1, to about 70% normal, with a 25% response to bronchodilator.. On an unknown date, Respiratory rate: more than 20 (High) More than 20. For mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular), the reporter did not provide any causality assessments. Patient did ECG and Blood troponins test.and studies included stress echo. Albuterol inhaler was used for treatment. Patient was sent to a cardiologist for increased BP management and had full workup to exclude infarct, studies included stress echo. Meds increased and BP was lowered, over a few weeks, but the dyspnoea did not improve. Following the second vaccine, also at about 48 hours, began coughing a lot, dry cough. It decreased over several weeks, now some days worse than others, but it is not bad at all now. Patient was referred to pulmonology and PFTs showed reduced FEV and FEV1, to about 70% normal, with a 25% response to bronchodilator. Since then used an albuterol inhaler before exercise and that helped walking a lot. Recently, past 3 weeks felt much better and stopped the inhaler. Was breathless on 1 flight of stairs, but can walk normally on flat ground now. The only other possibility was related to small hiatal hernia and felt that taking Omeprazole was possibly helping the coughing. So I am undergoing evaluation with a thoracic surgeon to determine whether there is reflux causing the coughing and a reactive bronchospasm. This case was linked to MOD-2021-297768 (Patient Link). Most recent FOLLOW-UP information incorporated above includes: n 30-Aug-2021: follow up received on 30 -aug-2021 contains Patient demographics, race and ethnicity were updated. Relevant history, lab data was added. concomitant and treatment medication were added. New adverse event and events outcome was updated.