Age: 72.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Peripheral coldness, SARS-CoV-2 test negative, Sinus pain, Speech disorder, Spinal osteoarthritis
Clinical narrative: terrible sharp shooting pain occurred frequently in my right sinus above my right eye; right side of my face and head went numb; terrible sharp shooting pain occurred frequently in my right sinus above my right eye; condition worsened, went to (name of hospital) ER; could not walk up the hill to door, placed in a wheel chair; probable TIA or stroke; probable TIA or stroke; slight imbalance & leaning to the right; This is a spontaneous report from a contactable consumer (patient). A 73-year-old male patient (age at vaccination: 72-year-old) received bnt162b2 (BNT162B2, lot EM9810), via an unspecified route of administration in right arm on 26Feb2021 12:30 as DOSE 2, SINGLE for covid-19 immunisation. Medical history included 2 incidents of pulmonary embolism (PE), no known allergies, melanoma, other skin cancers, fatty liver and had familial high cholesterol. Concomitant medications included apixaban (ELIQUIS), eszopiclone (LUNESTA), escitalopram oxalate (LEXAPRO), allopurinol and fish oil taken for an unspecified indication, start and stop date were not reported. The patient previously received bnt162b2 (lot EN6202) via unknown route in the right arm on 05Feb2021 12:30 (age of 72-year-old) for Covid-19 immunisation. On 12Apr2021 19:30, he had slight imbalance and leaning to the right. The patient experienced probable TIA (transient ischaemic attack) or stroke on 13Apr2021. His condition worsened 13Apr2021 19:30 and could not walk up the hill to door and was placed on the wheelchair. On 16Apr2021, the right side of the face and head went numb and felt a terrible sharp shooting pain that occurred frequently on the right sinus above the right eye. The events were serious- hospitalization duration of 2 days, life threatening and disability. The events resulted in doctor or other healthcare professional office/clinic visit, emergency room/department or urgent care. The patient had 12 weeks physical therapy as treatment.  The patient underwent laboratory tests and procedures which included blood test: unknown results on 13Apr2021, blood test: normal on 14Apr2021, computerised tomogram: unknown results on 13Apr2021  , echocardiogram: normal on 14Apr2021, magnetic resonance imaging head abnormal: normal on 14Apr2021, neurological examination: normal on 14Apr2021- neurologist came and performed some bedside tests , physiotherapy: normal on 14Apr2021 physical therapy tests for walking, balance, coordination, Sars-cov-2 test: negative on 13Apr2021, speech rehabilitation: normal on 14Apr2021 speech test , X-ray: unknown results on 13Apr2021. The outcome of events was recovered with sequel. Course of events: On 12Apr2021: slight imbalance & leaning to the right. On 13Apr2021: condition worsened, went to ER, could not walk up the hill to door, placed in a wheel chair, probable TIA or stroke, admitted to hospital, battery of tests initiated to look for TIA or stroke, blood work, COVID test, XRay, CT scan. On 14Apr2021: remained in hospital with more tests performed, Brain MRI, Echo Cardiogram. Neurologist came and performed some bedside tests, more blood work, speech test, physical therapy tests for walking, balance, coordination, etc. all tests were normal and imbalance was gone, discharged at 7:00 PM to go home. On 15Apr2021: imbalance & leaning to the right came back in the evening. On 16Apr2021 thru 18Apr2021: condition worsened to the point where he could not walk unassisted, right side of his face and head went numb, terrible sharp shooting pain occurred frequently in the right sinus above the right eye, only way to relieve pain was to sit reclined with ice pack on the right sinus.