Age: 62.0
Sex: F
Vaccine: COVID19
Symptoms: Arthropathy, Basophil count, Blood test, Cerebral atrophy, Cerebral small vessel ischaemic disease
Clinical narrative: Brain parenchymal volume loss; minimal probable small vessel ischemic disease; mild ethmoid mucosal thickening; small right maxillary retention cyst; Intense spasms for several days; Immediately had intense head pain on left side; numbness in face and left ear; Joint jerking starting that evening while I was at rest; This is a spontaneous report received from contactable reporter(s) (Consumer or other non HCP). The reporter is the patient.  A 62 year-old female patient (not pregnant) received bnt162b2 (BNT162B2), intramuscular, administered in arm left, administration date 15Apr2021 13:30 (Lot number: EW0164) at the age of 62 years as dose 1, single for covid-19 immunisation. Relevant medical history included: "Degenerative Disc Disease" (ongoing); "arthritis" (unspecified if ongoing); "hayfever" (unspecified if ongoing); "fibromyalgia" (ongoing); "depression and anxiety" (ongoing); "Food allergy" (unspecified if ongoing); "Drug allergy" (unspecified if ongoing); "seasonal allergies" (ongoing); "pain" (unspecified if ongoing). Concomitant medication(s) included: CITALOPRAM taken for anxiety, depression, pain, start date: 27Feb2020, stop date: 23Aug2021; TRAMADOL taken for pain (ongoing); VALIUM taken for anxiety (ongoing). Past drug history included: I had similar jerking with lyrica, reaction(s): "I had similar jerking with Lyrica". The following information was reported: CEREBRAL ATROPHY (medically significant), outcome "unknown", described as "Brain parenchymal volume loss"; CEREBRAL SMALL VESSEL ISCHAEMIC DISEASE (medically significant), outcome "unknown", described as "minimal probable small vessel ischemic disease"; HEADACHE (non-serious) with onset 15Apr2021 13:30, outcome "recovered", described as "Immediately had intense head pain on left side"; HYPOAESTHESIA (non-serious) with onset 15Apr2021 13:30, outcome "recovered", described as "numbness in face and left ear"; ARTHROPATHY (non-serious) with onset 15Apr2021, outcome "recovering", described as "Joint jerking starting that evening while I was at rest"; MUSCLE SPASMS (non-serious) with onset 15Apr2021 13:45, outcome "recovering", described as "Intense spasms for several days"; SINUSITIS (non-serious), outcome "unknown", described as "mild ethmoid mucosal thickening"; PARANASAL CYST (non-serious), outcome "unknown", described as "small right maxillary retention cyst". The events "immediately had intense head pain on left side", "numbness in face and left ear", "joint jerking starting that evening while i was at rest" and "intense spasms for several days" were evaluated at the physician office visit. The patient underwent the following laboratory tests and procedures: basophil count (0.0-0.3): (unspecified date) 0.0 kiU/L; basophil count: (unspecified date) 0.6 %; blood test: (04May2021) negative; eosinophil count (0.0-0.5): (unspecified date) 0.1 kiU/L; eosinophil count: (unspecified date) 2.1 %; haematocrit (36.0-48.0): (unspecified date) 37.7 %; haemoglobin (12.0-16.0): (unspecified date) 12.8 g/dl; immature granulocyte count (0.0-0.1): (unspecified date) 0.0 kiU/L; immature granulocyte count: (unspecified date) 0.2 %; lymphocyte count (1.8-4.0): (unspecified date) 2.0 kiU/L; lymphocyte count: (unspecified date) 41.3 %; magnetic resonance imaging: (unspecified date) there is symmetric prominence of the ventricles an; mean cell haemoglobin (26.0-35.0): (unspecified date) 30.8 pg; mean cell haemoglobin concentration (30.0-38.0): (unspecified date) 34.0 g/dl; mean cell volume (78.0-102.0): (unspecified date) 90.8 fmol/L; monocyte count (0.1-1.1): (unspecified date) 0.5 kiU/L; monocyte count: (unspecified date) 9.4 %; neutrophil count (1.8-7.0): (unspecified date) 2.2 kiU/L; neutrophil count: (unspecified date) 46.4 %; platelet count (150.0-450.0): (unspecified date) 194 kiU/L; red blood cell count (normal low range <1): (unspecified date) <1, notes: units:/100WBC'S; red blood cell count (4.0-5.50): (unspecified date) 4.15 MiU/L; red cell distribution width increased (11.5-16.0): (unspecified date) 13.3 %; white blood cell count (4.0-11.0): (unspecified date) 4.8 kiU/L. Therapeutic measures were not taken as a result of headache, hypoaesthesia. Therapeutic measures were taken as a result of arthropathy, muscle spasms.  Clinical course: The patient did not receive any other vaccines within four weeks prior to the vaccination. The patient receives Citalopram, Valium, Tramadol medications in two weeks prior to the vaccination. Prior to vaccination, the patient was not diagnosed with COVID-19. Since the vaccination, the patient had not been tested for COVID-19. No, specific relevant test for thromboembolic events with thrombocytopenia. Experience was frightening. Immediate face numbness and headache concerned me enough to contact CDC after GP suggested, Diazepam and did not seem concerned about getting 2nd dose. CDC recommendation to not get 2nd dose of mRNA vaccine. At this day, still have muscle twitching while at rest even with Baclofen. 2X a day ago, had not gotten a second dose and have questions. She had muscle jerking from Lyrica several years ago. MRI brain without and with contrast: Technique: 1.5T MR: Multiplanar/multisequence pre/postcontrast brain protocol. Contrast: 14 cc of Clariscan was administered intravenously, 1 cc of the contrast vial was discarded. Indication: Left-sided headaches. Left facial paresthesias. Dizziness and floaters. Muscle twitching. Comparison: 27Aug2014. Findings: Brain/meninges: There was symmetric prominence of the ventricles and sulci. A few scattered FLAIR hyperintensities in the supratentorial white matter are not specific but most suggestive of minimal small vessel ischemic disease. There was no acute intracranial hemorrhage or extra-axial fluid collection. There was no mass effect or midline shift. There was no restricted diffusion to suggest an acute infarct. A left frontal developmental venous anomaly again is noted. This was a developmental variant. There was no pathologic enhancement. Cranial nerves: Cranial nerves and basilar foramina appear normal as visualized. Parasellar: Pituitary gland, infundibulum, supraseller cistern and cavernous sinuses appear normal. Sinonasal: Nasal fossa, nasopharynx and parapharyngeal fascia appear normal. There was mild ethmoid mucosal thickening. There was a small right maxillary retention cyst. Craniofacial: Presumed degenerative pannus about the dens noted. Orbits appear normal as visualized. Mastoid and petrous air cells were clear. Vasculature: Visualized arterial intracranial flow voids were preserved. Impression: No acute intracranial findings. Brain parenchymal volume loss and minimal probable small vessel ischemic disease. Mild ethmoid mucosal thickening.  No follow-up attempts are possible. No further information is expected.