Age: 52.0
Sex: M
Vaccine: COVID19
Symptoms: Axillary mass, Balance disorder, Blood pressure measurement, Body temperature, Chills
Clinical narrative: This is a spontaneous report received from a contactable reporter(s) (Consumer or other non HCP). The reporter is the patient. A 52-year-old male patient received BNT162b2 (BNT162B2), on 05Jan2022 at 14:49 as dose 3 (booster), single (Lot number: 330368D) at the age of 52 years, in left arm for covid-19 immunisation. The patient's relevant medical history included: "ASD" (unspecified if ongoing), notes: Onset Date : Birth, Pertinent details - 24Feb1975 Open heart surgery; "VSD" (unspecified if ongoing), notes: Onset Date : Birth, Pertinent details - 24Feb1975 Open heart surgery; "Pulmonary valve repair" (unspecified if ongoing), notes: Onset Date : Birth, Pertinent details - 24Feb1975 Open heart surgery; "Open heart surgery", start date: 24Feb1975 (unspecified if ongoing); "AVR Implant" (unspecified if ongoing), notes: Onset Date : Birth, Pertinent details - 11Dec1995 Open heart surgery; "Removed subaortic membrane" (unspecified if ongoing), notes: Onset Date : Birth, Pertinent details - 11Dec1995 Open heart surgery; "Open heart surgery", start date: 11Dec1995 (unspecified if ongoing); "Heart rhythm issues" (ongoing), notes: Onset Date : Birth, Pertinent details - Right bundle branch block, Left Anterior fascicular block; "Right bundle branch block" (unspecified if ongoing); "Left Anterior fascicular block" (unspecified if ongoing); "Dysautonomia NCS + POTS", start date: 2000 (ongoing), notes: Pertinent details - Dizzy in standing position; "POTS", start date: 2000 (ongoing), notes: Pertinent details - Dizzy in standing position; "Dizzy in standing position" (unspecified if ongoing); "Low Vitamin D" (ongoing); "Hypertension" (ongoing); " Aortic Valve Implant" (ongoing); "Congenital heart disease with multiple repairs" (unspecified if ongoing). Concomitant medication(s) included: INFLUENZA taken for immunisation, on 08Dec2021 as single dose; AMLODIPINE oral taken for hypertension, start date: Jul2018 (ongoing); METOPROLOL TARTRATE oral taken for postural orthostatic tachycardia syndrome, start date: Jul2018 (ongoing); VITAMIN D [COLECALCIFEROL] oral taken for vitamin d decreased, start date: Feb2012 (ongoing); WARFARIN oral taken for aortic valve stenosis, start date: Dec1995 (ongoing); ZINC oral, start date: Apr2020 (ongoing). Vaccination history included: BNT162b2 (Dose 1, Single, Lot number- UNKNOWN), administration date: 05Mar2021, when the patient was 51-year-old, for COVID-19 Immunization; BNT162b2 (Dose 2, Single, Lot number- ER8727, Administration Time- 16:45, Anatomical Location- Left Arm), administration date: 26Mar2021, when the patient was 51-year-old, for COVID-19 Immunization, reaction(s): "4 days elevated heart rate 105-110", "Fever 101s for 3 days", "Joint pain 5 days", "Slight nausea - 2 days", "Significant chills for 10 days", "For 4-5 months, dizzy and lightheaded standing", "For 4-5 months, dizzy and lightheaded standing/Cannot stand to shower, brush/floss teeth, or perform household chores", "Presynope (Pre-syncope-lightheaded during every urination/bowel movement for 3.5 month", "Using extra chairs to stay in sitting", "Cannot stand to shower, brush/floss teeth, or perform household chores". The following information was reported: DECREASED APPETITE (non-serious) with onset 05Jan2022 at 17:05, outcome "recovered" (08Jan2022), described as "Decrease appetite/Diminished appetite"; DIZZINESS POSTURAL (non-serious) with onset 05Jan2022 at 17:05, outcome "recovered" (08Jan2022), described as "Dizzy upon standing/lightheaded during standing"; PALPITATIONS (non-serious) with onset 05Jan2022 at 17:05, outcome "recovered" (08Jan2022), described as "Racing heart"; CHILLS (non-serious) with onset 05Jan2022 at 17:30, outcome "recovered" (08Jan2022), described as "Feeling very cold with chills/Intermittent chills"; BALANCE DISORDER (non-serious) with onset 06Jan2022 at 08:07, outcome "recovered" (08Jan2022), described as "Feeling unsteady"; PYREXIA (non-serious) with onset 06Jan2022 at 08:07, outcome "recovered" (08Jan2022), described as "Patient temperature was 99.5 F, Fever lasted for two days"; DIZZINESS (non-serious) with onset 06Jan2022 at 09:00, outcome "recovered" (06Jan2022 at 16:00), described as "Dizzy spells"; VACCINATION SITE PAIN (non-serious), VACCINATION SITE SWELLING (non-serious) all with onset 2022, outcome "recovered" (2022) and all described as "His left triceps where he received the injection was painful and swollen"; AXILLARY MASS (non-serious) with onset 2022, outcome "recovered" (2022), described as "Swelling under left armpit/small lump under his left armpit"; PAIN IN EXTREMITY (non-serious) with onset 2022, outcome "unknown", described as "left arm pain". Relevant laboratory tests and procedures are available in the appropriate section. Therapeutic measures were taken as a result of palpitations, dizziness postural. Additional information: Patient was 52-years-old at the time of vaccination. Vaccination Facility type was reported as Pharmacy or Drug store. Vaccine was not administered at Military facility. Booster dose due to high risk of frequent institutional or occupational exposure to coronavirus (and at risk of serious COVlD-19 complications). Patient medical history included congenital heart disease with multiple repairs Dysautonomia - POTS + NCS. Patient Medical history (including any illness at time of vaccination) included ASD/VSD/Pulmonary Valve Repair from birth. On 24Feb1975, Open heart surgery. AVR Implant, Removed subaortic membrane from birth, on 11Dec1995 Open heart surgery. Ongoing Heart Rhythm Issues from birth, Right bundle branch block, Left Anterior fascicular block. Ongoing dysautonomia NCS + POTS from 2000 with Dizzy In standing position. Specific Relevant test included for thromboembolic events with thrombocytopenia performed INR test every 2 weeks with INR Values between 2.5 -3.5. Patient received influenza shot in left arm on 08Dec2021. Concomitant medications included ongoing Warfarin test (INR 2.5-3.5) via oral route of administration from Dec1995 for Aortic Valve Implant, ongoing Amlodipine at a dose of 2.5 mg/day via oral route of administration from Jul2018 for Hypertension, ongoing Metoprolol Tartrate at a dose of 43.75 mg/day via oral route of administration from Jul2018 for POTS/Tachycardia, ongoing Vitamin D at a dose of 1000 IU/day via oral route of administration from Feb2012 for low Vitamin D, ongoing Zinc at a dose of 5mg/day via oral route of administration from Apr2020. Patient third Pfizer COVID-19 vaccine shot was much more tolerable than his second shot. He was happy and grateful that he received his booster shot with minimal effects. On 27Dec2021 his COVID-19 Positive Spike antibody level was 2499 U/ml (same result as 17Aug2021). On 05Jan2022 at 17:05 diminished appetite started, and lasted 3 days (no nausea, just not hungry). Racing heart and dizzy upon standing. Took Metoprolol Tartrate and felt better in a little while. 05Jan2022 at 17:30 patient was feeling very cold with chills. Intermittent chills lasted through 08Jan2022. 06Jan2022 at 8:07 patient temperature was 99.5 F, fever lasted for two full days. Heart rate standing up out of bed was mid 90s before taking morning dose of Metoprolol Tartrate. After taking Metoprolol Tartrate heart rate was 80. A significant amount of feeling unsteady, lightheaded, during standing throughout the day. Also, from 09:00 to 16:00, he had some dizzy spells immediately after urination. 07Jan2022 at 08:10 patient temperature was 99.5 F. Heart rate standing up out of bed was upper 90s, before taking morning dose of Metoprolol Tartrate. After taking Metoprolol Tartrate heart rate was 80. A significant amount of feeling unsteady, lightheaded, during standing throughout the day. 08Jan2022 at 08:29 patient temperature was 98.0 F. Heart rate standing up out of bed was low 70s. before taking morning dose of Metoprolol Tartrate. After taking Metoprolol Tartrate heart rate was 59. Heart rate later dropped in early afternoon to 50. Minimal feeling unsteady, lightheaded during standing throughout the day. 09Jan2022, 08:00 Temperature was 96.9 F. Heart rate standing up out of bed was low 70s. before taking morning dose of Metoprolol Tartrate. After taking Metoprolol Tartrate heart rate was 50. Feeling back to normal today. Some normal lightheadedness during standing. Later in the day, he walked on the treadmill 26 minutes, and felt decent. Blood pressures, systolic 109 to 140 and diastolic 71 to 87 on an unspecified date. Higher numbers before first morning dose of Metoprolol Tartrate. Patient did not experience ridiculous BP spikes and vicissitude as when he received his second COVID-19 vaccine shot. His resting heart rate was back to his normal throughout the day, 48 to 60 bpm on an unspecified date. Also, his left triceps where he received the injection was painful and swollen for 4 days, with a small lump under his left armpit. The lump had disappeared.