Age: 57.0
Sex: F
Vaccine: COVID19
Symptoms: Mouth ulceration, Muscle spasticity, Paraesthesia oral, Rash papular, SARS-CoV-2 test
Clinical narrative: mouth tongue tingling and oral ulcer; mouth tongue tingling and oral ulcer; I woke up with Headache left, and with left side spastic weakness including face neck inner ear fullness and L.; Then on 27May2021, blister lesions 2 on Upper extremities and distal neck and small painful papular rash posterior scalp all disappear in 48hrs; Then on 27May2021, blister lesions 2 on Upper extremities and distal neck and small painful papular rash posterior scalp all disappear in 48hrs; I woke up with Headache left, and with left side spastic weakness including face neck inner ear fullness and L.; I woke up with Headache left, and with left side spastic weakness including face neck inner ear fullness and L.; Periorbital and eye strain with vision change mild diplopia.; Periorbital and eye strain with vision change mild diplopia.; This is a spontaneous report received from a contactable reporter(s) (Physician). The reporter is the patient.  A 57 year-old female patient (not pregnant) received bnt162b2 (BNT162B2), administered in arm left, administration date 13Jan2021 08:30 (Lot number: El0142) at the age of 57 years as dose 2, single for covid-19 immunisation. Relevant medical history included: "known allergies: PCn" (unspecified if ongoing); "Addison's on low dose prednisone 2.5mg" (unspecified if ongoing); "SVT" (unspecified if ongoing); "asthma" (unspecified if ongoing); "dysautonomia" (unspecified if ongoing); "menopause" (unspecified if ongoing); "migraine" (unspecified if ongoing); "lymphocytic vasculitis from skin biopsy of blister rash" (unspecified if ongoing); "microfibril neuropathy mild" (unspecified if ongoing); "suspect vzv" (unspecified if ongoing); "UMN inflammation" (unspecified if ongoing). Known allergies: Propafenone, PCn. Other medical history: Addison's on low dose prednisone 2.5mg, SVT, asthma, dysautonomia, menopause, migraine, h/o low Vit d, Vit b12. On May 27 event, lymphocytic vasculitis from skin biopsy of blister rash, and microfibril neuropathy mild, suspect vzv, &UMN inflammation. The patient's concomitant medications were not reported. No other vaccine in four weeks and no other medications in two weeks. Past drug history included: Propafenone, reaction(s): "Known allergies: Propafenone"; Addison's on low dose prednisone 2.5mg, notes: Addison's on low dose prednisone 2.5mg; H/o low vit d; Vit b12. Vaccination history included: Bnt162b2 (Dose Number: 1, Batch/Lot No: Ej1685, Location of injection: Arm Left, Vaccine Administration Time: 08:30 AM), administration date: 23Dec2020, when the patient was 57 years old, for COVID-19 immunization, reaction(s): "When I received first Pfizer vaccine 23Dec2020, after 24hrs sudden onset of extreme weakness"; Bnt162b2 (Dose Number: 1, Batch/Lot No: Ej1685, Location of injection: Arm Left, Vaccine Administration Time: 08:30 AM), administration date: 23Dec2020, when the patient was 57 years old, for COVID-19 Immunization, reaction(s): "confusion (inability read and comprehend patient chart)", "heavy head", "vision issue", "when stood up felt legs giving out or very weak", "migratory paresthesias on bilateral extremities"; Bnt162b2 (Dose Number: 1, Batch/Lot No: Ej1685, Location of injection: Arm Left, Vaccine Administration Time: 08:30 AM), administration date: 23Dec2020, when the patient was 57 years old, for Covid-19 immunization, reaction(s): "about every 3-4 weeks bulous lesion (1-2) with sharp pain on L.", "about every 3-4 weeks bulous lesion (1-2) with sharp pain on L.". The following information was reported: BLISTER (hospitalization, disability), RASH PAPULAR (hospitalization, disability) all with onset 27May2021, outcome "unknown" and all described as "Then on 27May2021, blister lesions 2 on Upper extremities and distal neck and small painful papular rash posterior scalp all disappear in 48hrs"; HEADACHE (hospitalization, disability), EAR DISCOMFORT (hospitalization, disability), MUSCLE SPASTICITY (hospitalization, disability) all with onset 27May2021, outcome "unknown" and all described as "I woke up with Headache left, and with left side spastic weakness including face neck inner ear fullness and L."; ASTHENOPIA (hospitalization, disability), DIPLOPIA (hospitalization, disability) all with onset 2021, outcome "unknown" and all described as "Periorbital and eye strain with vision change mild diplopia."; MOUTH ULCERATION (hospitalization, disability), PARAESTHESIA ORAL (hospitalization, disability) all with onset 06Nov2021, outcome "unknown" and all described as "mouth tongue tingling and oral ulcer". The patient was hospitalized for blister, rash papular, headache, ear discomfort, asthenopia, diplopia, mouth ulceration, paraesthesia oral, muscle spasticity (start date: 2021, hospitalization duration: 7 day(s)). The events "then on 27may2021, blister lesions 2 on upper extremities and distal neck and small painful papular rash posterior scalp all disappear in 48hrs", "then on 27may2021, blister lesions 2 on upper extremities and distal neck and small painful papular rash posterior scalp all disappear in 48hrs", "i woke up with headache left, and with left side spastic weakness including face neck inner ear fullness and l.", "i woke up with headache left, and with left side spastic weakness including face neck inner ear fullness and l.", "periorbital and eye strain with vision change mild diplopia.", "periorbital and eye strain with vision change mild diplopia.", "mouth tongue tingling and oral ulcer", "mouth tongue tingling and oral ulcer" and "i woke up with headache left, and with left side spastic weakness including face neck inner ear fullness and l." were evaluated at the physician office visit and emergency room visit. Adverse event: When I received first Pfizer vaccine 23Dec2020, after 24hrs sudden onset of extreme weakness, confusion (inability read and comprehend patient chart) and heavy head and vision issues, inability to type and fell asleep while typing, when stood up felt legs giving out or very weak. Took prednisone 20mg and fell asleep and after about 2 hrs woke up feeling fine. However on 27Dec started having migratory paresthesias on bilateral extremities and about every 3-4 weeks bulous lesion (1-2) with sharp pain on L. Lower extremity along with weakness. Then on 27May2021, blister lesions 2 on Upper extremities and distal neck and small painful papular rash posterior scalp all disappear in 48hrs but I woke up with Headache left, and with left side spastic weakness including face neck inner ear fullness and L. Periorbital and eye strain with vision change mild diplopia. I recovered by Aug, had recurrence 06Nov2021with additional symptoms mouth tongue tingling and oral ulcer. The patient underwent the following laboratory tests and procedures: sars-cov-2 test: (10Nov2021) negative, notes: Nasal Swab. Covid test post vaccination: covid test type post vaccination Nasal Swab, covid test name post vaccination PCR testing, covid test date 10Nov2021, covid test result Negative. Therapeutic measures were taken as a result of blister, rash papular, headache, ear discomfort, asthenopia, diplopia, mouth ulceration, paraesthesia oral, muscle spasticity. Ae treatment: Acyclovir and steroids.  No follow-up attempts are possible. No further information is expected.