Age: 88.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Cough, Vaccination site pain
Clinical narrative: Soresness beginning in arm and soreness in muscle on site on injection; This is a spontaneous report received from a contactable consumer. This consumer reported for the 88 years old male patient in response to the non-HCP letter who received BNT162B2 (PFIZER-BIONTECH COVID-19 mRNA VACCINE), dose 1 via an unspecified route of administration, administered in Arm Left on 23Jan2021 at 13:00 (Batch/Lot Number: EN6201; Expiration Date: Jun2021) as single dose covid-19 immunisation .  Patient's Medical History (including any illness at time of vaccination): Asthma Onset Date: 2010 Stop Date: ongoing (Pertinent Details: Cumulative, resulting in a 6.5 hour nasal cavity remaining & removal of polyp in 2013), Aspergillus fumigatus and Cardiac disease Onset Date: 2014 Stop Date: ongoing (Pertinent Details: heart valve replacement), Surgery history: In 1965 bi-lateral carpal tunnel relief, 06Jul77 bi-lateral foot reconstruction, 26Nov80 vasectomy, 1980 bi-lateral epididiectomy, 04Jun82 Reattach first joint rt. Index finger, 1983 Groin hernia repair, 1984 Rt. shoulder rotator cuff, 24Aug1987 Rt Knee arthroscopic, 09Sep1991 Left knee hemi-replacement, 1993 Tibia and ankle reconstruction (no bone union, redone 3/94 , union finally achieved & cast off in 7/94), 18Feb1994, 15Mar1994 and 22Apr1995 Rt leg alignment surgery, 04Dec1995 Rt. Elbow, 22Jan1997 Rt. Elbow, ulnar revision, 26Jun1997 Left total shoulder replacement, 24Jul1997 Rt. Elbow screw remove & Left Shoulder prosthesis revision, 11Nov1998 Left shoulder revision, Rotator cuff, 09Mar1998 Appendectomy, 29Oct1999 Rt. Elbow, 12Sep1999 and 12Sep2001 Rt. Foot, 31Mar2002 Rt. Elbow, 22Jan2003 Left foot, 01Dec2004 Rt leg BK amputation, 29Dec2004 Stump revision, 05Apr2005 Arm Surgery, 09Apr2005 post-surgical hematoma at surgery site, 03Jul2006 Dupatron left ring finger, 21May2007 Rt. Knee partial, left knee total replace, 21Sep2007 Knee Surgery, 10Mar2008 Rt. Elbow (revise ulnae nerve), 10Jun2010 Nasal polyp removal, 06Oct2010 Prostate TERP, 15Apr2011 Pacemaker installed, 16Mar2012 Broken right arm repaired, 30Apr2012 Left Ankle Replacement, 26Jul2013 Sinus Polyp removal (extensive 6-hour surgery), 28Aug2013 Revision: another total L ankle replacement (for failed 4/30/12 replacement), 26Nov2014 Heart: TAVR operation, 2015 Left leg BK amputation, 03Feb2017 Heart: WATCHMAN (LAAC) closure surgery and 15Jul2020 Reverse total shoulder (replacement of original replacement) Left shoulder); Hospitalization other than the above: 1934 (age 2): Popcorn grain on lung, 1960: Malaria, 1962: Viper snake bite, 2011: erratic heartbeat , 11Mar2012: Scooter Accident (11 broken ribs, punctured lung, right thigh hematoma, left arm nerve damage). Concomitant medication(s) included omalizumab (XOLAIR) taken for an unspecified indication from 15Jan2021 and ongoing.  The Patient received first covid vaccination on 23Jan2021. Soreness developed 2 days later on 25Jan2021 and increased in intensity until use of arm was severely limited because of muscle soreness on day 5 (28Jan2021). It was reported that the patient was hospitalized on unknown date for the event. Soreness persisted with such intensity that his second covid shot had to be delayed (as per order of his primary core physician) until 17Feb2021. At this writing on 08Mar2021, patient arm is still very sore upon waking but is slowly improving. The patient will be 89 in May and considering several co-morbities, has done well, despite the muscle soreness. The outcome of the event was not recovered.  The patient underwent relevant tests included blood tests, urine culture, diagnostic imaging (chest x-ray and MRI) on unknown date with unknown results.