Received Jun 27, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| COVID19 | COVID19 (COVID19 (PFIZER-BIONTECH)) | PFIZER\BIONTECH | 2 | FH8027 | IM |
1/9/2022: ER c/o 1.5 weeks cold/sinus symptoms with negative covid antigen. Left ear pain, ha, nausea, mild abd pain. 1/11-15/2022: 3rd ER visit with rt flank pain, nausea, dec appetite ..febrile (103), tachycardia, chills, neck stiffness, back pain, SOB [has hx of LBP, bilat breast prostheses, and migraines (PTSD/concussions) per med record review]. see below Assigned case number (redacted) Nov 17, 2021 Pfizer covid vaccine 12/14/21 Pfizer covid vaccine 1/9/2022: ER c/o 1.5 weeks cold/sinus symptoms with negative covid antigen. Left ear pain, ha, nausea, mild abd pain. 1/11-15/2022: 3rd ER visit with rt flank pain, nausea, dec appetite ..febrile (103), tachycardia, chills, neck stiffness, back pain, SOB [has hx of LBP, bilat breast prostheses, and migraines (PTSD/concussions) per med record review]. ER found partial rupt ovarian cyst, bilat basilar atelectatic, CSF study consistent with viral meningitis (see 1/11/2022 note) Dx viral meningitis and enteritis admitted seen by dermatology for truck/extremity salmon colored petechial rash.(1/19/2022 note-was on mult antibiotics, antiviral, NSAID, opioids, IV contrast, etc) --- 1/23/2022 discharge diagnoses: Adult onset stills disease, viral meningitis, enteritis, NSTEMII type 2, pulmonary edema, and acute hepatic injury 3/2022: 29yo AD Female referred to rheumatology for evaluation of AOSD. COVID vaccination in Jan developed cytokine storm like symptoms ultimately requiring hospitalization in early Jan m/b quotidian fevers, evanescent rash, leukopenia, arthralgias, pleural effusion, sore throat, myocarditis, high AST/ALT. Started on high dose steroids and increasing MTX at this time. Prednisone self tapered to 20mg daily and currently on 10mg weekly of MTX. pertinent positives include: Ferritin >4000-- >1321-- >82, CRP 36-- >2.7-- >.28, Negative ANA, RF, ANCA, HIV, C3/4, cultures. Radiology studies: Negative for lymphadenopathy by CTPA. Apr-May 2022: dx myocarditis: normal echo, cardiac MRI 2 months after onset chest pain, no significant findings noted in symptoms along with elevated troponin "are most consistent with a dx of myocarditis" after covid vaccine. Also diagnosed with AOSD on prednisone and methotrexate. 3/14/2025 Allergist documented discussion with Medical director Dr. advising "no evidence to extrapolate her request to all vaccines" but was granted exemption to covid-19 vaccinations. Case referred "formally to the (redacted)" per MD and he provided contact information to this patient. 6/27/2025: Continues to be seen by rheumatology, cardiology, neurology, psych, PCP and followed by case manager at facility. No contact from this patient to (redacted).
unknown
LBP, concussion, PTSD
unknown
PCN = rash