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From the 10/15/2021 release of VAERS data:

This is VAERS ID 1023948



Case Details

VAERS ID: 1023948 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Female  
Location: North Carolina  
Vaccinated:2021-02-06
Onset:2021-02-08
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 2 AR / IM

Administered by: Other       Purchased by: ?
Symptoms: Abdominal distension, Alanine aminotransferase increased, Aspartate aminotransferase increased, Bacterial test positive, Blood sodium decreased, Blood urine present, Cardio-respiratory arrest, Death, Decreased appetite, Fatigue, Feeling abnormal, Lymphocyte count increased, Neutrophil count increased, Prothrombin time prolonged, Resuscitation, Troponin increased, Urine abnormality, Urine analysis abnormal, White blood cell count increased
SMQs:, Torsade de pointes/QT prolongation (broad), Liver related investigations, signs and symptoms (narrow), Liver-related coagulation and bleeding disturbances (narrow), Anaphylactic reaction (broad), Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Acute central respiratory depression (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hyponatraemia/SIADH (narrow), Chronic kidney disease (broad), Proteinuria (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Vitamin C 500 mg daily Bisacodyl 10 mg daily Calcium Carbonate/Vitamin D 500/200 twice daily Clomipramine 100 mg twice daily Divalproex DR 1000 mg twice daily Levothyroxine 50 mcg daily Lisinopril 10 mg twice daily Metoprolol Succinate ER 5
Current Illness: No
Preexisting Conditions: Intellectual Disability Disorder Behavior Disorder (OCD/IED) Hypertension Hyperlipidemia Hypothyroidism Constipation Osteopenia
Allergies: Carbamazepine Loxapine Sulfa Antibiotics Tetracyclines Penicillins
Diagnostic Lab Data: 02/09/21: Urinalysis showed trace blood, cloudy and 2+ bacteria Na= 125 WBC = 13.6 Lymphocytes 6.7 ANC = 10.7 Labs from hospital showed elevated troponin = 155; PT = 22.6; ALT = 405, AST = 205
CDC Split Type:

Write-up: 02/08/21--2 days after vaccine--Resident stated that she "didn''t feel good" (She is developmentally delayed and less able to communicate how she feels than those in the community) and stopped eating most foods; also had fatigue. Vitals, coloring, & behavior were normal. 02/09/21--Belly was firm and mildly distended (although she stated it didn''t hurt); she coded this evening and CPR was performed before EMT could transport her to the hospital. 02/10/21--Resident passed.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1023948

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