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From the 11/26/2021 release of VAERS data:

This is VAERS ID 1017339

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Case Details

VAERS ID: 1017339 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-01-30
Onset:2021-02-05
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038K208 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Acute kidney injury, Cyanosis, Dyspnoea exertional, Laboratory test abnormal, Respiratory arrest, SARS-CoV-2 test negative, Troponin increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (broad), Myocardial infarction (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Furosemide Lasix, 20 mg PO daily at 0600 Simvastatin 20 mg Tablet PO daily Amlodipine Norvasc 2.5 mg Tablet PO daily Tamsulosin HCl 0.4 mg Capsle PO daily Dutasteride 0.5 mg Capsule PO daily Metroprolol Tartrate Lopressor 25 mg Tablet PO on
Current Illness: sob with exertion, started just prior to vaccine
Preexisting Conditions: A-fib Bladder cancer history CKD COPD HTN
Allergies: Penicillin hives Sulfonamide Antibiotics hives
Diagnostic Lab Data:
CDC Split Type:

Write-up: Admitted to hospital with sob upon exertion that started prior to vaccine. Hx COPD, HTN, CKD, hyperlipidemia, bladder cancer in remission. Stated he has been taking Eliquis and Xarelto between renal doctor and cardiologist Dr. Anticipating going home 2/5/21 but then turned blue and stopped breathing under a DNR. COVID test negative. Labs show acute on chronic renal failure with an elevated troponin likely from demand ischemia.


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