Age: 89.0
Sex: M
Vaccine: COVID19
Symptoms: Muscle rigidity, Musculoskeletal stiffness, Pleural effusion, Restlessness, Ultrasound bladder
Clinical narrative: Adverse cardiac events; bilateral pleural effusion; high blood pressure readings; UTI; diarrhea; localized inflammation; headache; elevated temperature; restless; sleepless; agitation; significant decrease in appetite; Prominent moaning and groaning; persistent cough; drooling; fluid retention; change in breathing pattern at night; faster heart rate; extreme rigidity in shoulders and body/joint/muscle stiffness and rigidity; labored breathing; congestion in throat and chest; congestion in throat and chest; days of complete fatigue; body/joint/muscle stiffness and rigidity; winded when walking/difficulty walking; dehydration; body/joint/muscle stiffness and rigidity; This is a spontaneous report received from contactable reporter(s) (Consumer or other non HCP).  A 89 year-old male patient received bnt162b2 (BNT162B2), administered in arm right, administration date 15Nov2021 13:30 (Batch/Lot number: unknown) at the age of 89 years as dose 1, single for covid-19 immunisation. Relevant medical history included: "Supra Nuclear Palsy" (unspecified if ongoing); "Known allergies: capital" (unspecified if ongoing). The patient took concomitant medications. Past drug history included: Sulfamethoxazole, reaction(s): "Known allergies: Sulfamethoxazole"; Amoxicillin, reaction(s): "Known allergies: Amoxicillin". The following information was reported: CARDIAC DISORDER (non-serious) with onset 15Nov2021 16:30, outcome "not recovered", described as "Adverse cardiac events"; PLEURAL EFFUSION (non-serious) with onset 15Nov2021 16:30, outcome "not recovered", described as "bilateral pleural effusion"; HYPERTENSION (non-serious) with onset 15Nov2021 16:30, outcome "not recovered", described as "high blood pressure readings"; URINARY TRACT INFECTION (non-serious) with onset 15Nov2021 16:30, outcome "not recovered", described as "UTI"; DIARRHOEA (non-serious) with onset 15Nov2021 16:30, outcome "not recovered", described as "diarrhea"; INFLAMMATION (non-serious) with onset 15Nov2021 16:30, outcome "not recovered", described as "localized inflammation"; HEADACHE (non-serious) with onset 15Nov2021 16:30, outcome "not recovered", described as "headache"; BODY TEMPERATURE INCREASED (non-serious) with onset 15Nov2021 16:30, outcome "not recovered", described as "elevated temperature"; RESTLESSNESS (non-serious) with onset 15Nov2021 16:30, outcome "not recovered", described as "restless"; INSOMNIA (non-serious) with onset 15Nov2021 16:30, outcome "not recovered", described as "sleepless"; AGITATION (non-serious) with onset 15Nov2021 16:30, outcome "not recovered", described as "agitation"; DECREASED APPETITE (non-serious) with onset 15Nov2021 16:30, outcome "not recovered", described as "significant decrease in appetite"; MOANING (non-serious) with onset 15Nov2021 16:30, outcome "not recovered", described as "Prominent moaning and groaning"; COUGH (non-serious) with onset 15Nov2021 16:30, outcome "not recovered", described as "persistent cough"; DROOLING (non-serious) with onset 15Nov2021 16:30, outcome "not recovered", described as "drooling"; FLUID RETENTION (non-serious) with onset 15Nov2021 16:30, outcome "not recovered", described as "fluid retention"; BREATHING-RELATED SLEEP DISORDER (non-serious) with onset 15Nov2021 16:30, outcome "not recovered", described as "change in breathing pattern at night"; HEART RATE INCREASED (non-serious) with onset 15Nov2021 16:30, outcome "not recovered", described as "faster heart rate"; JOINT STIFFNESS (non-serious) with onset 15Nov2021 16:30, outcome "not recovered", described as "extreme rigidity in shoulders and body/joint/muscle stiffness and rigidity"; DYSPNOEA (non-serious) with onset 15Nov2021 16:30, outcome "not recovered", described as "labored breathing"; UPPER RESPIRATORY TRACT CONGESTION (non-serious), RESPIRATORY TRACT CONGESTION (non-serious) all with onset 15Nov2021 16:30, outcome "not recovered" and all described as "congestion in throat and chest"; FATIGUE (non-serious) with onset 15Nov2021 16:30, outcome "not recovered", described as "days of complete fatigue"; MUSCLE RIGIDITY (non-serious), MUSCULOSKELETAL STIFFNESS (non-serious) all with onset 15Nov2021 16:30, outcome "not recovered" and all described as "body/joint/muscle stiffness and rigidity"; GAIT DISTURBANCE (non-serious) with onset 15Nov2021 16:30, outcome "not recovered", described as "winded when walking/difficulty walking"; DEHYDRATION (non-serious) with onset 15Nov2021 16:30, outcome "not recovered", described as "dehydration". The events "adverse cardiac events", "bilateral pleural effusion", "high blood pressure readings", "uti", "diarrhea", "localized inflammation", "headache", "elevated temperature", "restless", "sleepless", "agitation", "significant decrease in appetite", "prominent moaning and groaning", "persistent cough", "drooling", "fluid retention", "change in breathing pattern at night", "faster heart rate", "extreme rigidity in shoulders and body/joint/muscle stiffness and rigidity", "labored breathing", "congestion in throat and chest", "congestion in throat and chest", "days of complete fatigue", "body/joint/muscle stiffness and rigidity", "winded when walking/difficulty walking", "dehydration" and "body/joint/muscle stiffness and rigidity" were evaluated at the physician office visit. Relevant laboratory tests and procedures are available in the appropriate section. Therapeutic measures were taken as a result of cardiac disorder, pleural effusion, hypertension, urinary tract infection, diarrhoea, inflammation, headache, body temperature increased, restlessness, insomnia, agitation, decreased appetite, moaning, cough, drooling, fluid retention, breathing-related sleep disorder, heart rate increased, joint stiffness, dyspnoea, upper respiratory tract congestion, respiratory tract congestion, fatigue, muscle rigidity, gait disturbance, dehydration, musculoskeletal stiffness.  Additional information: The patient was neither diagnosed with Covid-19 prior to vaccination nor tested for Covid-19 post vaccination. The patient had not received any other vaccine within 4 weeks prior to vaccination. The patient received Thyroid medications within 2 weeks of vaccination. The patient underwent ultrasound of heart, lungs, bladder, kidneys. The patient received Lasix, baby aspirin daily, nattokinase, nitrofurantoin as treatment medications for resulted events. The patient received bnt162b2 (BNT162B2) on 12Dec2021 at 13:30 as Dose 2, Single, Lot number: FH8028.  The lot number for bnt162b2 was not provided and will be requested during follow up.