Age: 16.0
Sex: M
Vaccine: COVID19
Symptoms: Myocarditis, Pyrexia, Red blood cell sedimentation rate normal, SARS-CoV-2 antibody test, SARS-CoV-2 test
Clinical narrative: myocarditis; elevated troponin/troponin has been rising (up to 16); substernal chest pain at rest; shortness of breath; CRP to 87; abnormal EKG; headache; fevers; This is a follow up-spontaneous report from a contactable HCP (Nurse).  A 16-years-old male patient received bnt162b2 (BNT162B2), dose 2 via an unspecified route of administration on 24Apr2021 (Batch/Lot number was not reported) as 2ND DOSE, SINGLE for covid-19 immunization, at the age at vaccination of 16 years old. The patient medical history was not reported. NKA (No known allergies). Historical vaccine included first dose of BNT162B2 for covid-19 immunization. Concomitant medication included tretinoin (RETIN-A) 0.025 % cream taken for an unspecified indication, start and stop date were not reported. The patient experienced myocarditis, elevated troponin/troponin has been rising (up to 16), headache, fevers, substernal chest pain at rest, shortness of breath, crp to 87, abnormal EKG, all on 26Apr2021 with outcome of recovered on Apr2021. Reported as Patient with no significant PMH admitted on 4/26 with myocarditis, elevated troponin, and abnormal EKG. He states that he was feeling his usual self until the day that he received his 2nd dose of the COVID vaccine on 4/24. On 4/24, he started to have a headache and subjective fevers. On 4/26, he reported having substernal chest pain at rest, non-radiating, associated with shortness of breath. Patient took tylenol with minimal relief. Patient denies cough, congestion, abdominal pain, nausea, vomiting, diarrhea, rash. No sick contacts. Since admission, troponin has been rising (up to 16), BNP normal, CRP to 87, ESR normal, CBC and electrolytes unremarkable. Clinical course and findings consistent with myocarditis. ID consulted for infectious workup and management. In my prelim recs upon admission, I recommended a dose of IVIG and holding off on steroids and antibiotics.The patient underwent lab tests which included electrolytes: unremarkable on 26Apr2021, BNP: normal on 26Apr2021, c-reactive protein: to 87 on 26Apr2021, electrocardiogram: abnormal on 26Apr2021, CBC: unremarkable on 26Apr2021, ESR: normal on 26Apr2021, sars-cov-2 antibody test: positive on 29Apr2021 (Blood test), Symptomatic COVID-19 (Standard NAA): negative on 26Apr2021 (Nasal Swab), troponin: has been rising (up to 16)  on 26Apr2021, troponin: elevated on 26Apr2021. The events resulted in: Doctor or other healthcare professional office/clinic visit, Emergency room/department or urgent care, Hospitalization. The patient was hospitalized for events for 4 days. Treatment received for events. Patient had no covid prior vaccination. Prior to vaccination, the patient was not diagnosed with COVID-19.  Information about batch/Lot number has been requested.; Sender's Comments: The causal association cannot be excluded between the reported events and BNT162B2 use. The impact of this report on the benefit-risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for AE. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to regulatory authorities, ethics committees and investigators, as appropriate.