Sex: M
Vaccine: COVID19
Symptoms: Body temperature, Chills, Fatigue, Glycosylated haemoglobin, Headache
Clinical narrative: injection site soreness; tiredness; body ache; headache; fever peak 102.4; muscle soreness; chills; night sweats; This is a spontaneous report from a contactable consumer or other non-health care professional (patient).  A 65-year-old male patient received second dose bnt162b2 (COMIRNATY, PFIZER-BIONTECH COVID-19 VACCINE, formulation: solution for injection and Batch no: not reported/ Lot number: EN6204, Expiry date 30Jun2021) via intramuscular route of administration at right arm on 13Mar2021 10:30 (at the age of 65-year-old) as dose 2, single for COVID-19 immunization. Medical history included ongoing hypertension from 01Jan2000 (Controlled with MEDS successful mitral value prolapse repair since Nov 2004), Ongoing cholesterol from 01Jan2000 (Controlled with MEDS), ongoing herpes from 01Jun1985 (Controlled with MEDS as needed), ongoing sinusitis from 01Jun1992 (Controlled with MEDS), ongoing Rhinoplasty and ongoing Tympanoplasty both from since 1992. Contracted covid-19 from an unknown date in Mar2020 to unknown stop date. Concomitant medications included enalapril (VASOTEC) taken for hypertension, atorvastatin calcium (LIPITOR) taken for cholesterol, hydrochlorothiazide taken for hypertension, metoprolol tartrate (TOPROL XL) taken for hypertension, cetirizine hydrochloride (ZYRTEC) taken for sinusitis and valaciclovir hydrochloride (VALACYCLOVIR HCL) taken for herpes, all are ongoing from an unknown start date. Family history reported as none. Historical vaccine included patient previously received first dose bnt162b2 (COMIRNATY, PFIZER-BIONTECH COVID-19 VACCINE, formulation: solution for injection and Batch no: not reported/ Lot number: EN6200, Expiry date 30Jun2021) via intramuscular route of administration at right arm, on 20Feb2021 12:30 (at the age of 65-year-old) as dose 1, single for COVID-19 immunization and experienced fever up to 102 degrees, chills headache, tiredness, injection site soreness, sweats, feeling unwell. Patient stated that adverse events that she experienced with both doses of the Pfizer vaccine were very similar (But in a much shorter duration) to the actual adverse events she experienced when she contracted covid-19 back in March2020. Prior vaccinations were reported as none. On 13Mar2021 22:00, the patient experienced chills and tiredness, Headache and at 22:30 patient had body ache and muscle soreness, at 23:00 fever peak 102.4 and on an unknown date in Mar2021 after night sweats patient recovered from fever peak. On 14Mar2021 at 02:00 patient had Injection site soreness. Patient underwent lab tests and procedures which included Covid-19 Detected with (COBAS (R) SARS-CoV-2 test) on 20 Mar2020, A1C test results units 5 (Norm low: 4.8, Norm high: 5.6) on 10Nov2020, body temperature results 102.4 fever on 13Mar2021. Patient took treatment for fever peak 102.4, Body ache and muscle soreness, Headache with Tylenol. No treatment taken for other reported events. Outcome of fever peak 102.4 was recovered on 15Mar2021, Body ache and muscle soreness was recovered on 16Mar2021, Chills was recovered on 14Mar2021, headache was recovered on 16Mar2021, injection site soreness was recovered on 15Mar2021, Tiredness was recovered on 18Mar2021, night sweats was recovering.  No follow-up attempts are needed. No further information is expected.