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

This is VAERS ID 1021922



Case Details

VAERS ID: 1021922 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Kentucky  
Vaccinated:2020-12-29
Onset:2020-12-31
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Catheterisation cardiac normal, Chest pain, Myocarditis, Pyrexia
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: COVID-19
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Chest pain; Acute Myocarditis; Fever; A spontaneous report was received from a healthcare professional concerning a 35-year-old male patient who received Moderna''s COVID-19 Vaccine (mRNA-1273) and developed chest pain, myocarditis, and fever. The patient''s medical history included COVID-19 in Oct of 2020. No relevant concomitant medications were reported. On 29 Dec 2020 the patient received their first of two planned doses of mRNA-1273 (lot number or batch number not provided) intramuscularly (in the left arm) for prophylaxis of COVID-19 infection. On an unknown date after receiving vaccine the patient developed a fever and chest pain. On 31 Dec 2020 the patient was admitted to the hospital where a heart catheterization was done-negative results. The patient was diagnosed with myocarditis. He was scheduled to receive his second dose of vaccine on 03 Feb 2021. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not provided. The outcome of the events chest pain, myocarditis, and fever were not reported.; Reporter''s Comments: This case concerns a 35-year-old, male patient with a medical history of COVID-19, who experienced a serious unexpected event of chest pain, myocarditis and an expected event of pyrexia. The events of chest pain and pyrexia occurred on an unspecified date and the event of myocarditis occurred 3 days after the first dose of mRNA-1273. A heart catheterization was done-negative results.Very limited information regarding this event has been provided at this time. Based on temporal association between the use of the product and the start date of the event, a causal relationship cannot be excluded. Additional information has been requested.


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