Age: 69.0
Sex: F
Vaccine: COVID19
Symptoms: Abscess jaw, Biopsy skin, Body temperature, Chills, Computerised tomogram
Clinical narrative: This is a spontaneous report from a contactable consumer (patient). A 69-year-old female patient received second dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, Lot Number: ER2613) via unspecified route in left arm (in her left upper right below shoulder, in upper arm) single dose for COVID-19 immunization on 17Mar2021, at 69-year-old. Medical history included mild hyperparathyroid diagnosed 2 years ago (2019), autoimmune disorder, retinopathy; colon cancer; headaches because of her autoimmune disease. Concomitant medications included: formoterol fumarate, mometasone furoate (DULERA, inhaler) for autoimmune disease and asthma; vitamin D3 for supplement for osteoporosis in right hip and autoimmune fared up from 2019; cyanocobalamin (B12-VITAMIN) for supplement; ciprofloxacin 200 mg twice a day for 10 days from 03Mar2021; thyroid pill (unspecified). The patient previously took hepatitis B vaccine for hepatitis and experienced difficulty breathing; first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, Lot number: EN 6202) for COVID-19 immunisation on 25Feb2021 at 69-year-old and experienced sore throat, fever, lymph nodes enlarged, chills, lost weight; levothyroxine for hyperthyroidism from 1980; hydroxychloroquine sulfate (PLAQUENIL) from 1987 to 2013 and experienced systemic lupus erythematosus; prednisone; shingles shot (unspecified), felt bruising and hot where they put it but did not last long. The patient had a fever again after the second vaccine. By the time she got home, when she waited the half hour, she felt like she was starting to get a fever because her face was starting to fever. Sometimes she had headache and fevers and swollen lymph glands and not to this extent that she had, it was from the COVID vaccine. She probably had headaches at the same time of the fevers and took paracetamol (TYLENOL) 500 mg for headache. The patient added she also had headaches too in the beginning and with the second vaccine. She also had chills and sore throat. Two days after the second shot (19Mar2021), her swelling got worse with her lymph nodes and pain got worse after she got better. She was put on antibiotics. For the lymph nodes enlarged, the patient reported on the 31Mar2021 she was in pain extremely bad, she felt a large lump in jaw area. She should have taken pictures of her face, her whole face right side was swollen and enlarged. She went back to her doctor on 31Mar2021 and he said it was going to take longer because of her immune system for things to get better. Last time she saw a doctor, since the other stuff happened, she thought maybe it is a tooth causing this. On 08Apr2021, she went to the dentist and they had difficulty because she could not open her mouth. They were shocked they could not open her mouth, so they did a surround head X-ray which showed no abscess and that her teeth were fine. She had a round of antibiotics, so she was off her second round of antibiotics on 26Mar2021 and was not doing better. The dentist told her do not let it go much longer because her face was red and large and by the time she saw the dentist that lump was larger, and her face and jaw and that area was getting pretty bad. Treatment was reported included: the second antibiotic was from a different doctor, on 19Mar2021, then from 20Mar2021 levofloxacin 500 mg once a day for seven days. She went to the ENT and she said something else was wrong, something else was going on. 19Apr2021 the patient went to the ENT nurse practitioner who did a CAT scan and was not thinking COVID-19. She was thinking different things that turned out to be negative. On 28Apr2021 the CAT scan of neck showed some inflammation, parotid gland looked alright but there was some inflammation. She started running a fever and her normal temperature was 97.4-97.9, but it was 102 on 01May2021. On 01May2021, she was in a lot of pain and her jaw got worse, she had difficulty eating and opening her mouth. That evening (01May2021), she fall asleep and woke up to drainage coming out of her jaw. Just a little bit, it was white. She thought it was an abscess and used warm hot compresses. Sunday (02May2021), it got worse with the drainage and pain. A skin and tissue biopsy was done and squeezing out the rest of the puss or fluid. Pathology said the reports came back no cancer cells or bacterial or fungus, just a lot of inflammation. The patient still had trouble with draining so they gave her antibiotics, she thinks bacitracin. The fluid all came out and she stopped the fever and pain was better. Inflammation was going down. There was nothing draining inside her mouth, just below her jaw underneath. She had a small lump and tenderness that was starting to heal. One small patch finally stopped draining red and skin had not healed. The patient felt so much better than in February and March. Outcome of the events fever, drainage coming out of her jaw/ thought it was an abscess was resolved; outcome of the events headache, chills, sore throat, red face, difficulty eating was unknown; outcome of the other events was resolving.