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From the 10/8/2021 release of VAERS data:

This is VAERS ID 1014895



Case Details

VAERS ID: 1014895 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: Foreign  
Vaccinated:2021-01-20
Onset:2021-01-21
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9788 / 2 - / OT

Administered by: Other       Purchased by: ?
Symptoms: Circulatory collapse, Peripheral vascular disorder, Vomiting
SMQs:, Anaphylactic reaction (narrow), Acute pancreatitis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (narrow), Hypovolaemic shock conditions (narrow), Toxic-septic shock conditions (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypoglycaemic and neurogenic shock conditions (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypersensitivity (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: PANTOPRAZOLE; METOCLOPRAMIDE; ACETYLSALICYLIC ACID; TORASEMIDE; AMLODIPINE; SIMVASTATINE
Current Illness: Cardiac insufficiency; Coronary heart disease
Preexisting Conditions: Medical History/Concurrent Conditions: Acute renal failure; Arterial hypertension; Arteriosclerosis; Cardiac failure; Cerebral ischaemia; Chronic gastritis; COVID-19 respiratory infection; Multi-infarct dementia; Pneumonia; Upper gastrointestinal haemorrhage; Vomiting
Allergies:
Diagnostic Lab Data:
CDC Split Type: DEPFIZER INC2021103840

Write-up: hypotonic circulatory failure; Circulatory collapse; Vomiting; This is a spontaneous report from a non-contactable physician downloaded from the Medicines Agency (MA) Regulatory Authority-WEB other manufacturer number DE-DCGMA-21187686. A female 91-year-old patient, born on PRIVACY, was vaccinated with the second dose of BNT162B2 (COMIRNATY, batch no.: EK9788) for COVID-19 immunisation, Intramuscular on 20Jan2021. Concomitant medications included: pantoprazol, metoclopramide, acetylsalicylic acid, torasemid, amlodipin, simvastatin Patient past drug therapy: Comirnaty (start date: 28Dec2020, No adverse reaction). Medical history included: Pneumonia, Acute renal failure, Upper gastrointestinal haemorrhage, Multi-infarct dementia, COVID-19 respiratory infection, Arterial hypertension, Cerebral ischaemia, Arteriosclerosis, Chronic gastritis, Cardiac failure, Vomiting, Coronary heart disease, Cardiac insufficiency. 1 day after vaccination the patient developed Vomiting and Circulatory disorder peripheral and Circulatory failure, lasting for 4 hour(s). The patient is dead. Death cause was reported as Circulatory failure. ADDITIONAL INFORMATION ON DRUG PROVIDED IN PRODUCT NOTES: Second vaccination Adverse events: increasing hypotensive circulatory failure in the following hours, no response to infusion therapy, bradycardic arrhythmia, asystole/death at 11.15 am. 1st Covid-19 vaccination on 28Dec2020 was well tolerated; pat was in good, stable until 20Jan21, 2nd Covid-19 vaccination on 1/20Jan2021; sudden onset of symptoms described above starting at approximately 7 am on 21Jan2021. Measures: Considering the patient''s age and general condition with infusion therapy. Supplement for Reporter''s comments: Ringer''s lactate, 1 MCP 10 mg ampoule IV, later Akrinor IV from the emergency doctor; no stat. Instruction or resuscitation (living will was available) No follow-up attempts are possible. No further information is expected.; Reporter''s Comments: Adverse events: increasing hypotensive circulatory failure in the following hours, no response to infusion therapy, bradycardic arrhythmia, asystole/death at 11.15 am. 1st Covid-19 vaccination on 28Dec2020 was well tolerated; pat was in good, stable until 20Jan21, 2nd Covid-19 vaccination on 1/20Jan2021; sudden onset of symptoms described above starting at approximately 7 am on 21Jan2021. Measures: Considering the patient''s age and general condition with infusion therapy; Reported Cause(s) of Death: Circulatory failure


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