Age: 59.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Gait disturbance, Magnetic resonance imaging head, Nausea, Scan brain, Strabismus
Clinical narrative: It has gone from vertigo to dizziness and feeling off balance with specific head positions. ; vestibular neuritis; Crystals have dislodged in the inner ear; It has impacted his gait pattern, and has impacted his ability to do things without dizziness or a sensation of being off balance; Intense vertigo; nauseous; Dynamic balance control deficits/ feeling off balance with specific head positions/ balance disruptions; Visual deficits; cross-eyed; couldn't focus on anything and it looked like what was on the left was on the right, and vice versa; visual acuity was impacted; This is a spontaneous report received from a contactable reporter(s) (Consumer or other non HCP) from medical information team. The reporter is the patient.  A 59-year-old male patient received BNT162b2 (BNT162B2), on 04Feb2021 as dose 2, single (Lot number: EK4176) at the age of 59 years, in left arm for covid-19 immunisation. The patient had no relevant medical history. There were no concomitant medications. Vaccination history included: BNT162b2 (Dose 1, single, Lot number: EL0140), administration date: 14Jan2021, when the patient was 59-year-old, for COVID-19 immunization. The following information was reported: BALANCE DISORDER (non-serious) with onset 01Apr2021, outcome "unknown", described as "Dynamic balance control deficits/ feeling off balance with specific head positions/ balance disruptions"; VERTIGO (non-serious) with onset 01Apr2021, outcome "not recovered", described as "Intense vertigo"; NAUSEA (non-serious) with onset 01Apr2021, outcome "not recovered", described as "nauseous"; VISUAL IMPAIRMENT (non-serious) with onset Apr2021, outcome "recovered" (2021), described as "Visual deficits"; VISION BLURRED (non-serious) with onset Apr2021, outcome "recovered" (2021), described as "couldn't focus on anything and it looked like what was on the left was on the right, and vice versa"; STRABISMUS (non-serious) with onset Apr2021, outcome "recovered" (2021), described as "cross-eyed"; VISUAL ACUITY REDUCED (non-serious) with onset Apr2021, outcome "recovered" (2021), described as "visual acuity was impacted"; VESTIBULAR NEURONITIS (medically significant), outcome "unknown", described as "vestibular neuritis"; DIZZINESS (non-serious), outcome "unknown", described as "It has gone from vertigo to dizziness and feeling off balance with specific head positions. "; EAR DISORDER (non-serious), outcome "unknown", described as "Crystals have dislodged in the inner ear"; GAIT DISTURBANCE (non-serious), outcome "unknown", described as "It has impacted his gait pattern, and has impacted his ability to do things without dizziness or a sensation of being off balance". The events "vestibular neuritis", "intense vertigo", "nauseous", "it has gone from vertigo to dizziness and feeling off balance with specific head positions. " and "dynamic balance control deficits/ feeling off balance with specific head positions/ balance disruptions" required physician office visit. The patient underwent the following laboratory tests and procedures: Blood test: (01Apr2021) Normal; Electroencephalogram: (Jul2021) Normal; Magnetic resonance imaging head: (10Apr2021) Normal; (Aug2021) Normal; Scan brain: (Jul2021) Normal, notes: some other type of scan of his brain. Clinical course: The patient had a serious and intense reaction that he can only trace back to the 2nd dose of the vaccine. It started with a lot of different symptoms. Intense vertigo: Explains that he could be sitting still but the room is moving around and around him until he becomes nauseous. It has gone from vertigo to dizziness and feeling off balance with specific head positions. Visual deficits: He was cross-eyed for several weeks. He couldn't focus on anything and it looked like what was on the left was on the right, and vice versa. His visual acuity was impacted; he couldn't focus. This started on 2Apr2021 or 3Apr2021, a couple days after the vertigo started. It took about a month before being cross eyed went away. Then he had the visual acuity problems and couldn't focus on anything. The visual acuity portion took another month or two to go away. He was recovered by May2021 or Jun2021. Neurological or balance disruptions, dynamic balance control deficits: States that this comes and goes; sometimes he seems like he has improved, but when he tries to go back to doing the things he used to he gets dizzy all the time again. This is the primary symptom that has lingered. It has impacted his gait pattern, and has impacted his ability to do things without dizziness or a sensation of being off balance. Since this began he has been unable to treat patients like he normally would, by engaging in vestibular rehab like he did as a therapist. Normally he would be able to bounce a large ball to someone and have them bounce it back to him without him feeling like he is ready to loose his balance and fall over. Clarifies that the intensity comes and goes, but has never really gone away; he was unable to choose an outcome. The patient went to a doctor 23Jan2023 and he introduced him to an article about post vaccine syndrome and an approach to managing post vaccine syndrome. He was also looking for a physical therapist for vestibular neuritis rehab, a condition he never experienced before. Stated he doesn't even know where to begin. He feels like he is banging his head against the wall; clarifies that he is not literally banging his head against the wall. Investigations: He went to hospital on 01Apr2021. Then did blood draws, but all his labs looked normal. They recommended that he get an MRI of his brain, which he did on 10Apr2021, and that was normal. They recommended that he see a Neurologist, who evaluated him about a month later and he was diagnosed with vestibular neuritis. He went to an ENT about a month later, as recommended by the Neurologist, and they did an Eppleys maneuver, which is for someone whose crystals have dislodged in the inner ear and they were trying to get the crystals back where they were supposed to be. His symptoms didn't get better so he went to a 2nd Neurologist. States he asked the 1st Neurologist if he had heard of any direct links to the vaccine and he was not willing to discuss that with him, so he decided to go to the 2nd Neurologist. He did an EEG, and some other type of scan of his brain around Jul2021. All the tests came back negative, and he was told that they didn't see anything wrong with him and to go back to the ENT. He went to hospital and had a 2nd MRI of the brain in Aug2021. His symptoms were still occurring but the MRI was negative.