Age: 28.0
Sex: M
Vaccine: COVID19
Symptoms: Blood bilirubin, Blood bilirubin increased, Coagulopathy, Feeling abnormal, Full blood count
Clinical narrative: It has been 50 odd days since his first dose of the Pfizer BioNTech Covid-19 Vaccine; His coagulation ended; The only thing elevated was he had a slightly elevated bilirubin.; Petechia rash on parts of his legs and a little bit on his feet. Also on his arms in a couple spots and on his stomach and chest.; This is a spontaneous report from a contactable consumer or other non hcp (patient). A 28-years-old male patient received bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE, solution for injection), dose 1 via an unspecified route of administration on 20Mar2021 13:00 (at the age of 28 years) (Batch/Lot Number: EP7534) as DOSE 1, SINGLE for covid-19 immunisation. Medical history included ongoing Penicillin allergy and Allergic to Sulfa (he was a baby or one year old). Allergic to Seafood (since he was around 4 or 5) from an unknown date. He had hives with that also. Concomitant medication included vitamins nos (DAILY MULTIVITAMIN) taken for an unspecified indication, start and stop date were not reported (He had been on the same one for the last 10 years). Prior to vaccination he reported, He has had normal reactions like a sore arm but nothing like this. His arm gets sore when he gets the annual flu shot for probably about a day. When he had the tetanus shot his arm hurt for about a day. He had an HPV shot but never finished that series, and it hurt for about a day. Generally, when he gets a shot it hurts for about a day. He had no NDC, lot, or expiration date available for any of the vaccines that gave him a sore arm. Patient was just instructed by his health department to call in and report an adverse event he had to the first dose of the Pfizer BioNTech Covid-19 Vaccine. He got the first dose on 20Mar2021, and on 23Mar2021 he noticed a petechia rash on parts of his legs and a little bit on his feet. He had to go to the emergency room, and they did bloodwork there. His platelet levels were fine. All of his bloodwork was fine. They discharged him the same night. The rash persisted and would disappear and then reappear elsewhere on his body. It was always petechia. He followed up with his primary doctor and had more blood tests there as well. The blood tests always came back within the normal ranges. His platelets never dropped, and his sedimentation rate was normal. His coagulation ended up being normal. The rash would sort of come and go and pop up lasting for a couple days, the spots would fade, then it would pop up again somewhere else. It was primarily on his legs and on his arms in a couple spots and on his stomach and chest. He consulted a dermatologist. The dermatologist looked at it and confirmed it was a petechia rash. Since his bloodwork was fine, he said he could get the second dose of the vaccine and reported it to the health department. It is kind of a strange predicament he is in. He had a dermatologist instruct him to get the second dose, they thought it was fine last week was what they told him. He shot an email off to the local health department, and at this point now it has been 50 odd days since his first dose. He is still getting spots here or there, and he wanted to see what they would say. They said the CDC said they had a cut-off date at 42 days, and he was wondering if he could get the second dose after 42 days. He asked the health department and they said because he had an adverse reaction it could disqualify him from getting the second dose. He did not know if he can get the second dose. He also reported, It technically would had been the night of 22Mar2021 that he noticed the rash. He did not go to the emergency room until 2200 or 2300 that night. He first noticed it on the night of 22Mar2021. It continued intermittently with different spots up until now. He has had no new spots since last week. He thinks it was the longest he has gone since March without anything. When he did see the dermatologist, the most recent patch of spots had faded, and he was going off pictures he took. Last week on Sunday 25Apr2021 he noticed more spots pop up on his arms. He scheduled the dermatologist appointment because his doctor said to since his blood work was done, and he saw a decent sized patch pop up. He called to schedule a dermatology appointment. The appointment was on Wednesday 28Apr2021. It was between 25Apr2021 and 28Apr2021 that the petechia started to fade. They completely faded by 29Apr2021 or 30Apr2021. He had not seen any new ones since then. He started something on the suggestion of his dermatologist. He said something like the vaccine could have caused some kind of immune response that affected the dilation of his blood vessels. He said to take 500mg of Vitamin C daily because it did something to the blood vessels. He started that daily. Since then, he had not noticed any spots, and he was hopeful that he did not notice any in the future. He did not know if he can say it had recovered completely since it had just been a few days, but he hopes it had. He spent the last 16 months pretty much homebound because he lived with 2 people who were at high risk. He went with everyone else in the household and they got the vaccine at the same time. He just wanted to get protection so that he could not worry. Investigations included He was admitted to the emergency room at about 2300 on 22Mar2021. He was discharged from the emergency room at like 0100 on 23Mar2021. They did a physical exam, and it didn't blanch where it was located. Then they did a CBC with differential that all came back good. The only thing elevated was he had a slightly elevated bilirubin. His platelet count was at 180,000 so that was within the normal range of 150,000 to 400,000. Every time he had his blood tested, they did a CBC, and his platelets are always within range around 180,000. He went to the doctor's office a couple days after he was in the emergency room. The only time he was ever admitted was at the emergency room that night for a few hours, then he went to the doctor office a week after because the rash faded then showed up elsewhere. He had a physical done and followed up with the same doctor in the office a week after because more spots showed up. He had another set of blood test somewhere around 10Apr2021. After that he waited it out but still got more spots, and that is when he went to the dermatologist last week. The patient underwent lab tests and procedures which included blood bilirubin: slightly elevated on 22Mar2021, full blood count: good on 22Mar2021, platelet count: 180,000 on 22Mar2021. The clinical outcome of all the events was unknown. No follow-up attempts are needed; information about lot/batch number cannot be obtained.