Age: 53.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Erythema, Feeling hot, Joint swelling, Myalgia, Pain in extremity
Clinical narrative: pain all up the arm/As time passed the pain progressed up her arm. She couldn't straighten arm at all/When she lifts her arm up, it is still sore/her right arm wrist also has pain; now she also has pain in her right wrist/pain has started to increase in her left arm wrist/her right arm wrist also has pain; swelling at the injection site; left shoulder inoculation site edema/edema is minimal; left ear was burning; left eye had floater; left hand and wrist were double the size of right hand/it was so swollen it was a bite/because of the swelling. She couldn't even bend her knuckles at all; swelling in the right wrist/wrist doubled the size of right hand/it was so swollen it was a bite; entire arm where the vaccine was given was red and swollen/swelling in her left arm has increased; entire arm where the vaccine was given was red and swollen.; arm was warm; she has cried; intramuscular pain; This is a spontaneous report from a contactable consumer (patient). A 53-year-old female patient received first dose BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, Lot Number: EW0182), intramuscular at the age of 53-year-old administered in arm left on 06May2021 10:40 at single dose for covid-19 immunisation. Medical history included chronic anemia, pulmonary embolism in both lungs (doesn't remember the years but she had 4 or 5 of them/maybe between 2016 and 2019), didn't have a bladder from Apr2020 (cystoscopy performed in Apr 2020), dehiscence of wounds, gastric bypass from Jul2007, two major blood clots in right arm from 2019 (because of infiltrated IV. One was 7mm and one was 8mm. A piece broke off of one of them within 24 hours and went into right lung), Smoker, allergy to antibiotics, slightly topical itch reaction to Morphine, cat scratch infection, had a reaction to IVP dye for kidney scan where her eyes started swelling. Concomitant medication included gabapentin (NEURONTIN) taken for left knee nerve pain from Mar2021 and ongoing. The patient previously took Doxycycline and experienced anaphylactic reaction, morphine and experienced slightly topical itch reaction. She received her first Pfizer COVID19 Vaccine on 06May2021 which was a Thursday. Everything was fine. Shot was in left arm. Wednesday, last week, which was six days later she woke up with her entire left hand and wrist doubled the size of right hand on 12May2021. A friend of hers is her in home nurse because caller has underlying health issues. They thought because it was so swollen it was a bite. Caller did Benadryl and RICE treatment. As the day progressed, she had pain all up the arm on 17May2021. She had an appointment with physical therapy. They said to get to the hospital. Her nurse met her for lunch and caller's arm was warm in May2021 and her nurse said to get to the ER. They wanted to rule out a blood clot. They didn't want to admit her, but she had severe issue with her arm that day. She was given pain medication, Benadryl, and had CT scan to rule out blood clot in ER.  She couldn't move her neck to the left. She was there 8 hours. While there, her left ear was burning (on 12May2021) to the point it felt someone was ripping it off. In her left eye she had floater on 12May2021, like black fuzzy lines. Everything was on the left side. She didn't hit anything in the time between receiving the injection and 6 days later. She had not done nothing out of her normal routine. It is too much of a coincidence that this is the only thing she has had in the left arm. For 2 or 3 days since last Wednesday the entire arm where the vaccine was given was red and swollen in May2021. She didn't have an immediate side effect, but 6 days later she had a great amount of side effects. She can't say it is the vaccine. She has had a flu shot every year and pneumonia shot every 5 years with no side effect. She is anaphylactic or resistant to every oral antibiotic. Even with IV antibiotics there are only certain ones that can be use, but she has to be pretreated with 50mg of IV Benadryl. She was on Doxycycline all last summer oral and IV. After 4 weeks on it she was sent home with a temp medline for IV infusion. Within 3 hours of her giving herself the next dose she had an anaphylactic reaction. Her body does not immediately react to any side effects or adverse reaction. It can be days out and it hits all of a sudden. On last Wednesday she woke up around 7AM. She felt like it woke her up because of the swelling. She couldn't even bend her knuckles at all. As time passed the pain progressed up her arm. She couldn't straighten arm at all. Everything was on that Wednesday and on the left side. She had full range of motion on the right side. The hospital said it was intramuscular and she read that could possibly be side effect. This was her first dose. Left hand and wrist were double the size of right hand: It resolved. She noticed it around 7AM as the day progressed the swelling went down a little bit. That is when the arm started hurting and the swelling would come back. The swelling wasn't as significant as it was first thing in the morning. She has pictures she can provide if needed. Pain all up the arm: the pain has resolved except for the top of the arm where she received the vaccine. When she lifts her arm up, it is still sore. It wasn't sore the first 2 to 3 days or immediately following the inoculation. It is still very mildly sore. They also did an ultrasound when in the ER. At home she takes, not for this issue, Gabapentin 3 times a day. It was just filled and is in the pharmacy vial and she doesn't have NDC, lot, and expiry. Caller clarified that it is Neurontin 300mg not Gabapentin. She has been on Neurontin since Mar2021. She takes it for left knee nerve pain. For the pain meds she was given in the ER and the Benadryl she doesn't have NDC, lot, or expiry. The hospital administered 100mg of Benadryl. When they did the CT scan they did it with contrast. 40 years ago she had a reaction to IVP dye for kidney scan where her eyes started swelling. Anytime she has contrast solution she is always treated with 50mg of IV Benadryl. She has a slightly topical itch reaction to Morphine. In the ER, they gave her 40mg of IM morphine because they couldn't get a line going. She basically has no veins. They gave her 50mg of Benadryl subcutaneously in the inner area. Then before the CT with contrast, they gave her another 50mg of Benadryl. What she took at home was off brand. It is called Banophen Diphenhydramine HCI 25mg antihistamine. She took one when the reaction happened. The manufacturer is Major. NDC: 09045551-59. When providing NDC caller states, "Come on eyes." Lot number: P121325. Expiry: Aug 2022. Caller just found a sugar cookie from Panera Bread to eat. She was in (withheld) in mid October to late October. Unfortunately when she was down there with her best friend her cat scratched her and caller ended up in the hospital because of cat scratch infection. Even though they were very cautious and following all the CDC guidelines and wearing mask when she came home for 5 days she had many COVID symptoms. She went for a rapid test and it came up negative. She has been tested 15 times since last year because she has had so many surgeries. The reason she got the vaccine was with her underlying health conditions she doesn't want to die. What is interesting is her husband and son both after she felt ill coming home had the same symptoms she did. She is scheduled to get her next dose 27May2021. Is that normal to be scheduled 3 weeks apart? Her greatest concern is her nurse provider is not familiar with her. Her GI doctor and orthopedic surgeon said she should be ok. She wants to receive both as recommended. Her concern with the second vaccine is if the side effects that she experienced could be dramatically worse or result in a horrible outcome. When she spoke to the physician and the nurses and the medical care team they said there are no studies or reports where the vaccine is causing blood clots and what she was experiencing was not associated with the vaccine. When she looked up the vaccine, it said that intramuscular issues could be a rare side effects. Her thought was that it wasn't reported that it hasn't happened. Could intramuscular issues be a rare side effect? Caller clarified that she does not have the Doxycycline or any other antibiotics that she is resistant to or had reaction with to provide NDC, lot, and expiry. The last time she had it was when she had the temp medline put in. She had the reaction and spoke to the infectious disease doctor only in hospital. She threw all the vials and all the bags away. She torn up the lot numbers. The actual bottles she soaked them and then flushed the labels down the toilet. She has chronic anemia. It has been brought to her attention lately that she has critically low iron saturation. Low saturation should be 18 and her iron saturation level was a three. She had the blood test on the same day of the vaccine on 06May2021. On the 7th she had iron infusion. The vaccine was given at 10:40AM. The blood work was drawn at 02:40PM. The iron infusion was at 9:30AM on 07May2021. She received one unit. Adds she previously reported she had gotten the Pfizer COVID 19 vaccine and six days later she had severe side effects. States she was encouraged by her health care professional to go to the ER to rule out a blood clot which she did and the result was negative. Adds when she had the first dose of the vaccine 06May2021, intramuscular in the left shoulder; she had no side effects or anything. Six days later her left hand was swollen to double the size of the right had. She took a 25mg Benadryl that did nothing, which she previously reported. Adds at lunch yesterday she spoke to a friend who is an in home care nurse who has taken care of her before because of her other medical problems; and she encouraged the caller to do RICE treatment; rest, ice, compression and elevation for her wrists. This friend saw the hand at lunch and noticed that the caller was unable to straighten the left elbow and arm; she had great pain in the left elbow and from the hand up the arm. All of these events were previously reported. Caller mentions she is in so much pain and her symptoms are getting worse. New events reported today include the pain has started to increase in her left arm wrist; swelling in her left arm has increased. Caller mentions the physical therapist saw the edema especially on the left shoulder at the vaccination (inoculation) site on 17May2021 and said there is still swelling and she had not noticed this before. Caller clarifies later that day around 1700PM 17May2021, the caller attended a physical therapy treatment and the therapist noticed swelling at the injection site on 17May2021 which was not previously reported. Adds as the day went on yesterday, her right arm wrist also has pain; since yesterday through last night and today it has been at a 10. Adds she has cried in May2021. Mentions she feels she has limited use of her fingers that she noticed yesterday when she had the wrist pain; even picking up things or trying to chop chicken, she can't; she doesn't think she mentioned particularly the left wrist yesterday. Her main concern today is that the pain in her left wrist has increased and now she also has pain in her right wrist on 17May2021. Caller adds she put muscle rubs on; and ice. Her pain in her wrists has not responded to the Gabapentin. She applied three different topical solutions with no improvement in her pain: Generic muscle rub from store; Natureplex Ultra Strength muscle rub; NDC 67324002-01; Jul2022;Topical 5% pure lidocaine cream; Lot 20G13C1; Jul2022; OTC from the pharmacy, no box. Voltaren Gel; Dec2019; lot WN791; unable to locate NDC due to pain in her wrist. Adds the swelling on both wrists is minimal but the pain is incredible; excruciating. Just the edema is minimal; she has kept ice on it on and off; 20 minutes on and off. Adds she has never had pain like this before. Caller mention she did speak with doctor yesterday. Adds she was greatly upset when they told her after she had explained all of her symptoms, that intramuscular joint pain had been detected in May2021. The events results in Emergency Room Visit. The patient underwent lab tests included blood test: unknown results on 06May2021, Iron saturation: low (Low saturation should be 18 and her iron saturation level was a three) on unknown date, CT scan (to rule out blood clot): unknown results, ultrasound: Unknown results, COVID test: negative. The outcome of event left ear was burning and left eye had floater was recovered on 12May2021, the outcome of event Swelling of wrists, Vaccination site oedema and Wrist pain was not recovered and other events was unknown.