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

This is VAERS ID 1034116



Case Details

VAERS ID: 1034116 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Female  
Location: Virginia  
Vaccinated:2021-01-19
Onset:2021-01-30
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Biopsy skin abnormal, Blister, Dermatitis, Epidermal necrosis, Rash, Skin exfoliation, Toxic epidermal necrolysis
SMQs:, Severe cutaneous adverse reactions (narrow), Anaphylactic reaction (broad), Malignancy related therapeutic and diagnostic procedures (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Skin tumours of unspecified malignancy (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   Days after onset: 16
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Escitalopram 10mg tablet Novolin 70/30 Insulin Diazepam 2mg tablet Simvastatin 20mg tablet Acetaminophen 500mg tablet
Current Illness: Diabetes - Type 2 Dementia CVA s/p L-sided weakness Psychiatric disorder
Preexisting Conditions:
Allergies: Buspirone Morphine
Diagnostic Lab Data: Surgical Pathology reports: FINAL DIAGNOSIS: SKIN, RIGHT THIGH, BIOPSY: SUBEPIDERMAL BULLAE WITH EXTENSIVE EPIDERMAL NECROSIS AND MIXED INFLAMMATORY INFILTRATE. NO EVIDENCE OF MALIGNANCY. Comment: The clinical concern for toxic epidermal necrolysis is noted, and the histologic findings support this impression. Extensive subepidermal bullous formation with associated mixed inflammatory infiltrate composed of neutrophils, eosinophils, and lymphocytes is noted in the larger of the two skin fragments, while the smaller fragment shows diffuse epidermal necrosis, which is compatible with TEN.
CDC Split Type:

Write-up: Presented from clinic with 3-4 days of extensive rash. There were multiple areas of skin sloughing on bilateral upper extremities and abdominal wall.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1034116

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