Age: 30.0
Sex: M
Vaccine: COVID19
Symptoms: Magnetic resonance imaging, Mobility decreased, Muscle tightness, Neck pain, Ultrasound scan
Clinical narrative: took him a half an hour just to get out of bed; Tightness to left trapezius and left side of neck, same side as vaccine; increased pain and decreased range of motion to his neck; increased pain and decreased range of motion to his neck; inflammatory infectious process with atypical organisms; Lymphadenopathy/ compressing the nerves in his neck and causing his pain and decreased range of motion; This is a spontaneous report from a contactable nurse (patient). A 30-year-old male patient received the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE lot number: ER8730) via an unspecified route of administration, administered on the left arm on 31Mar2021 15:00 at a single dose for COVID-19 immunisation. Medical history included ongoing hypothyroid. Concomitant medication included levothyroxine sodium taken for hypothyroid. The patient previously received tetanus vaccine (6 weeks out from his Covid Vaccine) with no adverse events. Patient stated that his side effects began on 01Apr2021. He noticed tightness to left trapezius and left side of neck. This was the same side of the body he got the vaccine on. His symptoms worsened over the next two days. He had increased pain and decreased range of motion to his neck. On Saturday 03Apr2021. it took him a half an hour just to get out of bed. Stated that he went to the Emergency Room at the hospital where he works and they did a series of tests. He had CAT Scans with and without contrast, a MRI, and an Ultrasound. Mentioned later that they also did blood work (Apr2021). The Emergency Room doctor told the caller he was going to have his CAT scan read by a specialist. Caller stated they called him on Sunday 04Apr2021 and said his CAT scan showed an inflammatory infectious process with atypical organisms and Lymphadenopathy. He stated that he read that Lymphadenopathy was a side effect of the vaccine. They told him that the Lymphadenopathy was compressing the nerves in his neck and causing his pain and decreased range of motion. He had been on a week of treatment consisting of pain medications, muscle relaxers, and anti-inflammatory medications. The Infectious Disease was consulted and he was started on a 5 day course of Azithromycin. He was on the third day of this antibiotic per his report. He has a follow up MRI scheduled next Friday. He was calling to report his side effects and also to ask about what he should do in regards to his appointment for his second dose of the vaccination. His symptoms were worsening for the first three days. Since he has been being treated for them they have started to improve slowly day by day. Today he said there was minimal pain and tightness but he was still not back to one hundred percent. He was offered admission to the hospital for pain control after his emergency room visit but he decided to defer it to an outpatient setting. Was not admitted to the hospital. The patient felt that the events 'tightness to left trapezius and left side of neck, same side as vaccine'; 'increased pain and decreased range of motion to his neck' were medically significant and stated they were disabling, at least temporarily. There were no additional vaccines administered on same date of Pfizer suspect. Outcome of the events 'tightness to left trapezius and left side of neck, same side as vaccine'; 'increased pain and decreased range of motion to his neck' was recovering while unknown for the other events. Patient stated that he felt all of his adverse events were caused by the COVID Vaccination he received.; Sender's Comments: A contributory role of BNT162B2 to reported events cannot be excluded based on the temporal relationship. Case will be  reassessed if additional information is received. 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 adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified.