Age: 32.0
Sex: F
Vaccine: COVID19
Symptoms: Anti-cyclic citrullinated peptide antibody, Anti-thyroid antibody, Antinuclear antibody, Blood corticotrophin, Blood cortisol
Clinical narrative: COVID-19 infection; COVID-19 infection; Dizziness, orthostatic hypotension; Palpitations, postural orthostatic tachycardia; Chest pain, shortness of breath, fatigue, anxiety, memory, concentration and word finding difficulty; This literature-non-study case was reported in a literature article and describes the occurrence of the first episode of COVID-19 (COVID-19 infection) and the second episode of COVID-19 (COVID-19 infection) in a 32-year-old female patient who received mRNA-1273 (Spikevax) for COVID-19 prophylaxis. The occurrence of additional non-serious events is detailed below.       No Medical History information was reported.   In February 2021, the patient received first dose of mRNA-1273 (Spikevax) (unknown route) 1 dosage form. In March 2021, received second dose of mRNA-1273 (Spikevax) (unknown route) dosage was changed to 1 dosage form. In 2021, the patient experienced the first episode of COVID-19 (COVID-19 infection) (seriousness criterion hospitalization), the second episode of COVID-19 (COVID-19 infection) (seriousness criterion hospitalization), ORTHOSTATIC HYPOTENSION (Dizziness, orthostatic hypotension), POSTURAL ORTHOSTATIC TACHYCARDIA SYNDROME (Palpitations, postural orthostatic tachycardia) and POST-ACUTE COVID-19 SYNDROME (Chest pain, shortness of breath, fatigue, anxiety, memory, concentration and word finding difficulty). The patient was hospitalized from sometime in June 2021 to sometime in 2021 due to COVID-19, and then from sometime in September 2021 to sometime in 2021 due to COVID-19. The patient was treated with MIDODRINE at a dose of 10 milligram three times a day and PROPRANOLOL at a dose of 20 milligram, 2-3 time daily. At the time of the report, last episode of COVID-19 (COVID-19 infection), ORTHOSTATIC HYPOTENSION (Dizziness, orthostatic hypotension), POSTURAL ORTHOSTATIC TACHYCARDIA SYNDROME (Palpitations, postural orthostatic tachycardia) and POST-ACUTE COVID-19 SYNDROME (Chest pain, shortness of breath, fatigue, anxiety, memory, concentration and word finding difficulty) outcome was unknown.      DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): In 2021, Anti-cyclic citrullinated peptide antibody: Negative. In 2021, Anti-thyroid antibody: Negative and Negative. In 2021, Antinuclear antibody: Negative. In 2021, Blood corticotrophin (0-47 picogram per millilitre): 20 picogram per millilitre. In 2021, Blood cortisol (5.3-22.5 microgram per decilitre): 19 microgram per decilitre. In 2021, Blood iron: Negative. In 2021, Blood pressure measurement: ranged from 110/78 to 124/82 while lying and from 85/45 to 103/59 while standing.. In 2021, Blood thyroid stimulating hormone (0.358-3.74 international unit per millilitre): 2.36 international unit per millilitre. In 2021, Echocardiogram: small PFO. In 2021, Full blood count: Negative. In 2021, Glycosylated haemoglobin: 4.9 %. In 2021, Heart rate: ranged from 88 to 96 while lying and from 130 to 42 while standing.. In 2021, Metabolic function test: Negative. In 2021, Red blood cell sedimentation rate (0-20 mm/hr): 4 mm/hr. In 2021, Rheumatoid factor: Negative. In 2021, Thyroxine free (0.76-1.46 ng/dL): 0.97 ng/dL. In 2021, Troponin: Negative. In 2021, Tryptase (Unknown-<11 microequivalent per litre): 3.7 microequivalent per litre. In 2021, Vitamin B12 (193-986 pg/ml): 480 pg/ml. In 2021, Vitamin D: 24.3 ng/mL.     For mRNA-1273 (Spikevax) (Unknown), the reporter did not provide any causality assessments.  Company Comment: This is a literature non-study case concerning a 32-year-old female patient with no medical history reported, who experienced unexpected serious (hospitalization) event of Covid-19 which occurred twice. First COVID-19 occurred after vaccination with 1st and 2nd dose of mRNA-1273 app. 4 and 3 months respectively and second COVID-19 occurred after vaccination with 1st and 2nd dose of mRNA-1273 app. 7 and 6 months respectively. It is of importance to note that the patient has also experienced non-serious events of post-acute Covid-19 syndrome, orthostatic hypotension and postural orthostatic tachycardia. Symptoms of these conditions occurred initially after first COVID-19 hospitalization and some have worsened after second COVID-19 hospitalization. Following the first hospitalization, the patient developed severe orthostatic hypotension, chest pain, shortness of breath, fatigue, anxiety, memory, concentration and word finding difficulties. The patient followed a regimen of adequate hydration, adequate salt intake, fall precautions, physical and speech therapy and high protein/low carb diet with frequent snacks, which improved symptoms of dizziness and orthostasis, but without complete resolution. However, anxiety, dizziness, chest pain and palpitations became even worse after the second hospitalization. Propranolol (20 mg 2-3 times daily) treatment was introduced and improvement has been observed. Diagnostic work up performed enabled to exclude alternative causes of hypotension; no abnormalities that could serve as explanation were found in following tests: cortisol, ACTH, TSH, fT4, B12, Hba1c, 25 OH Vitamin D, tryptase, ESR, CBC, CMP, TPO and Tg antibodies, troponin levels, iron studies, ANA panel, Rheumatoid factor, anti-CCP antibodies, myasthenia gravis panel, CT head and MRI brain, EKG and QTc interval. Echo revealed small PFO. The events of orthostatic hypotension and postural orthostatic tachycardia have been assessed as not related to the vaccine but in accordance with authors who postulated that events are related to a virus- or immune-mediated disruption of the autonomic nervous system resulting in orthostatic intolerance syndromes. For events of COVID-19 and post-acute Covid-19 syndrome causality has been assessed as not applicable due to the lack of biologic plausibility. The benefit-risk relationship of mRNA-1273 vaccine is not affected by this report.   No concomitant medications were reported.  Following the first hospitalization, she developed severe orthostatic hypotension, chest pain, shortness of breath, fatigue, anxiety, memory, concentration and word finding difficulty. She followed a regimen of adequate hydration, adequate salt intake, fall precautions, physical and speech therapy and high protein/low carb diet with frequent snacks, which improved her symptoms of dizziness and orthostasis, but without complete resolution. However, symptoms of anxiety, dizziness, chest pain and palpitations became even worse after the second hospitalization which was in Sep 2021. Post-acute COVID referred to persistent symptoms 3 weeks after COVID-19 infection, while Chronic COVID describes symptoms lasting more than 12 weeks. Symptoms include fatigue, dyspnea, chest pain, palpitations, dizziness, body aches, presyncope and orthostatic intolerance. Individuals may even develop post-traumatic stress disorder, panic attacks and irritable bowel syndrome. Orthostatic intolerance occurs due to release of epinephrine and norepinephrine leading to development of palpitations, breathlessness, and chest pain. It has been well described that orthostatic intolerance is preceded by viral infections and is associated with the development of autoantibodies a-/ß-adrenoceptors and muscarinic receptors. COVID 19 itself can affect the autonomic nervous system through the release of a cytokine storm leading to sympathetic activation. It is crucial to consider the diagnosis of orthostatic intolerance syndromes post COVID infection.  Myasthenia gravis panel negative, CT head and MRI brain, EKG and QTc interval results not provided.