Age: 72.0
Sex: F
Vaccine: COVID19
Symptoms: Aphonia, Cerebrospinal fluid leakage, Chills, Condition aggravated, Headache
Clinical narrative: loses her voice; she just sat down in a chair, and everything went black for a second; second COVID-19 Vaccine exasperated her spinal cord leak symptoms because her lightheadedness, and equilibrium being off, started on 25Mar2021; second COVID-19 Vaccine exasperated her spinal cord leak symptoms because her lightheadedness, and equilibrium being off, started on 25Mar2021; She hurt more, too, in her L4 & L5 vertebrae; not feeling well; body was aching/She hurt more, too, in her L4 & L5 vertebrae, and had pain throughout her whole body.; Headache; Chills; Her Oral Lichen Planus was more pronounced since her second COVID-19 Vaccine dose; Her Oral Lichen Planus was more pronounced since her second COVID-19 Vaccine dose; This is a spontaneous report from a contactable consumer (patient). A 72-years-old female patient received second dose of bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE; Batch/Lot Number: ER2613), via an unspecified route of administration, administered in Arm Left on 24Mar2021 13:53 (at 72-years-old) as single dose for COVID-19 immunization. Medical history included ongoing Spinal leak (Diagnosed with a spinal leak about 1-1/2 years ago. She said she has had spinal leaks, on and off, since that time.), ongoing Oral lichen planus (Stated she was diagnosed with Oral Lichen Planus between 10-15 years ago), ongoing Rheumatoid arthritis (Stated she was diagnosed with Rheumatoid Arthritis at least 3 years before she was diagnosed with Oral Lichen Planus. She said she had been tested for food allergies & as long as she stayed away from gluten, chicken, tomatoes & some other things, she did not have a problem with her rheumatoid arthritis. She said gluten, in particular,  triggered her rheumatoid arthritis.), Gluten (triggered her rheumatoid arthritis), fractured her L4 vertebrae in last summer 2020, sciatica from Feb2020 (pinched sciatic nerve since Feb2020), Bone density issue. Stated her family has a history of autoimmune diseases, like Lupus. Concomitant medications included diphenhydramine, paracetamol (EXTRA STRENGTH TYLENOL PM, NDC Number: 50580-937-19, Lot Number: SLA006, Expiration Date: Aug2024); ibuprofen (ADVIL, UPC Number: 305730154604, Lot Number: EG1007, Expiration Date: Jul2023); gabapentin ("ACI Health", Expiration Date of 05Mar2022). The patient previously took first dose of bnt162b2 (Lot number: EN6198) on 02Mar2021 (at 72-years-old) Intramuscular on left arm for covid-19 immunization but experience Left arm was sore, left arm soreness went away after 2-3 days. The patient previously took Flu vaccine but experienced Mouth sores. Reported she had both COVID-19 Vaccine doses. She said she got the typical side effects of a headache, chills, not feeling well, and her body was aching. She clarified those side effects started late the night of her second COVID-19 Vaccine shot (24Mar2021). She said those side effects were mild, and resolved in about 2 days. She said she didn't think much of those side effects, until the next day (25Mar2021), when the other side effects started (blacked out, lightheaded, equilibrium was off). She said her left arm was sore after her first COVID-19 Vaccine dose. She said she didn't treat her left arm soreness, and the left arm soreness went away after 2-3 days. Reported on 25Mar2021 at about 11:30AM, she blacked out. She said she just sat down in a chair, and everything went black for a second. She said she then got really lightheaded, and her equilibrium was off. Reported she had spinal leaks, on and off, for the past 1-1/2 years. She clarified that her doctors didn't think the spinal cord leaks would be contraindicated with the COVID-19 Vaccine. She said all her doctors said it was up to her if she wanted to get the COVID-19 Vaccine because she previously had problems with the flu vaccine. She clarified she had a flu vaccine about 15 years ago, and the day after the flu vaccine, she got mouth sores, and the mouth sores got worse. She said her local doctors didn't know how to treat her mouth sores, so she went to the clinic. She said the clinic doctors told her she had Oral Lichen Planus, and the Oral Lichen Planus was caused by the flu vaccine she had received. She stated she did not have any information (NDC, Lot, & Expiration Date) for the flu vaccine she received back then. She stated she has not had a flu vaccine since that time. Reported her spinal cord leaks caused equilibrium, and lightheadedness. She said she thought her second COVID-19 Vaccine exasperated her spinal cord leak symptoms because her lightheadedness, and equilibrium being off, started on 25Mar2021 11:30. She said her lightheadedness, and equilibrium being off was still going on. Reported she hurt more, too, in her L4 & L5 vertebrae, and had pain throughout her whole body. She clarified she fractured her back (specifically her L4 vertebrae) last summer (2020), and her L4 vertebrae had since healed. She said she had a pinched sciatic nerve since Feb2020. She clarified her L4 and L5 vertebrae move because she had 3 blood patches to treat her spinal cord leaks. She said when the blood patches were done a lot of force was used to stop the spinal leaks. She said the first blood patch caused her buttocks to really hurt. She said she had 2 more blood patches. She said she was not too sure about second blood patch, but with the 3rd blood patch, she was miserable. She said she had physical therapy weekly, and she may have to have her back fused. She said she had a bone density issue that apparently was mentioned in her medical records when she was in her 50s. She said she was never treated for her bone density issue until after she fractured her L4 vertebrae in 2020. No further details provided. Reported her last blood work was 3-4 months ago. No further details provided. Reported her Oral Lichen Planus was more pronounced since her second COVID-19 Vaccine dose (Mar2021). She clarified she started to get Oral Lichen Planus mouth sores a couple days after she received her second COVID-19 Vaccine. She said she can go months without having any issues, and then get the Oral Lichen Planus mouth sores. She said she took medication to manage her Oral Lichen Planus. She said with the medication, the Oral Lichen Planus mouth sores are gone within 24-48 hours. She said with her latest Oral Lichen Planus mouth sores, she put her medication on the mouth sores, and the mouth sores seemed to settle down, but the mouth sores didn't go away completely. She said the day before yesterday (03Apr2021), her Oral Lichen Planus mouth sores got worse again, and are staying that way, even with using the medication. Oral Lichen Planus Treatment: Stated she was applying Clobetasol Propionate Ointment UPS 0.05% to her mouth sores after she eats, or about 3-4 times a day. NDC Number: 51672-1259-6, Lot Number: 332450, Expiration Date: Aug2021. For other treatment she had medication she takes every day, and she continued to take the medication to help her symptoms. She said she had physical therapy twice a week for about 1-1/2 hours, as well as, doing physical therapy on her own. She clarified she does the physical therapy for her sciatica and vestibular issues, saying she was not steady on your feet. She said she does physical therapy about 4 hours a week. Reported her doctors told her she would not survive the Corona Virus if she were to get it because of her underlying health issues. No further details provided. Reported her doctors said there was no information reporting that the COVID-19 Vaccine was contraindicated in people with spinal cord leaks, and how the COVID-19 Vaccine would affect people with spinal cord leaks. She said she thought she may have been fighting things because the COVID-19 Vaccine was acting like the flu vaccine (when she first developed Oral Lichen Planus). She said she thought her symptoms after her second COVID-19 Vaccine dose  may have had something to do with her spinal cord leak because she had similar symptoms (lightheadedness & equilibrium issues) with her spinal cord leak. She said with her spinal cord leak, she also had pain and loses her voice. No further details provided. The outcome of the events she just sat down in a chair, and everything went black for a second was recovered on 25Mar2021; headache was recovered in Mar2021; chills was recovered in Mar2021; not feeling well was recovered in Mar2021; body was aching/she hurt more, too, in her l4 & l5 vertebrae, and had pain throughout her whole body was recovered in Mar2021; loses her voice was unknown; while for other events was not recovered.