Adverse Event Reporting
| VAERS ID | 991101 |
|---|---|
| Gender | Male |
| Age | 62 |
| StateCode | NC |
| Pharmaceutical Company | PFIZER\BIONTECH |
| Lot Number | |
| Number of vaccinations | 1 |
| Vaccinated | 2020-12-22 |
| Onset | 2021-01-01 |
| Condition | Hospitalized Permanent Disability |
Symptoms
- Fatigue
- Hypoaesthesia
- Dyspnoea
- Muscle fatigue
- Muscle spasms
- Muscular weakness
- Nerve conduction studies abnormal
- Facial paralysis
- Balance disorder
- Gait disturbance
- Dyspnoea exertional
- Demyelination
- Facial paresis
- Grip strength decreased
- Immunoglobulin therapy
- Guillain-Barre syndrome
- Electromyogram abnormal
- Forced expiratory volume
- Forced expiratory volume decreased
- Pulmonary function test abnormal
- Tidal volume decreased
Current Illness
none but had flu vaccine in Nov of 2020
Preexisting Conditions
diabetes
Other Medications
chlorthalidone, dapagliflozin-metformin, armour thyroid, melatonin
Previous Vaccinations
Allergies
none
Laboratory Data
NCS/EMG 1/28/21 PFT/NCS ? 1/26
Write-up
Patient reports having his flu vaccination in November 2020 and his Pfizer COVID-19 vaccination on 12/22/2020.
10 days later he noticed bilateral leg cramps subsequently leading to numbness in his feet, weakness in his feet, numbness on side of his legs, both hands and upper back.
2 to 3 days prior to admission on 1/2/21 he has noticed right-sided facial weakness andhas noticed increasing shortness of breath on exertion.
He was initially seen by PCP who suspected Guillain-Barré syndrome and had a PFT done which showed reduced tidal volume and FEV1 He was seen by neurologistand had EMG nerve conduction studies which confirmed demyelination & patient has been sent to the hospital for IVIG treatment.
Per PT note from 1/30: "UE ROM: WFL UE Strength: WFL, reports grip weaker from baseline LE ROM: WFL LE Strength: proximal WFL, ankle DF/ PF 2+/3-/5 Coordination: reports no deficits with finger to nose B Sensation: numbness B hands; B feet numbness and reports weight bearing feels like standing on something squishy Balance: WFL over level surfaces, able to compensate with strength Posture: midline Other: R side facial droop, able to close R eyelid Bed Mobility: mod independent Transfers: modified independent, no device; able to perform controlled eccentric lowering stand > sit Gait Level of Assistance: Modified independent, requires aide device or extra time Assistive Device: None Distance Ambulated (ft): 10 ft Gait: pt ambulating in room without device, appears mildly unsteady with decreased heel strike with increased foot flat contact, mild increased lateral postural sway (increased with retrowalk).
No frank LOB.
Stairs: verbally reports has been performing stairs sineonset of symptoms, stairs are hard but able to perform, improved with UE support when available, requires increased time and fatigues quickly Endurance: neuromuscular fatigue, requires increased rest breaks" He was admitted to hospital from 1/28-2/2 for 5 treatmens of IVIG.
He had improvement of his SOB and numbness but has not had full resolution of symptoms.