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

This is VAERS ID 1038442



Case Details

VAERS ID: 1038442 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-01-04
Onset:2021-01-06
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 AR / IM

Administered by: Other       Purchased by: ?
Symptoms: Blood chloride increased, Blood creatinine increased, Blood glucose increased, Blood potassium increased, Blood sodium increased, Blood urea increased, Death, Drug screen positive, Glomerular filtration rate decreased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Retroperitoneal fibrosis (broad), Drug abuse and dependence (broad), Chronic kidney disease (broad), Tumour lysis syndrome (narrow), Tubulointerstitial diseases (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-06
   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: Hospital discharge medications 12/28/20: Tylenol prn; ativan prn; morphine prn; scopolamine prn all other medications were discontinued
Current Illness: Inpatient 12/21/20 with COVID (+ test 12/17/20) and cellulitis of leg treated with antibiotics. Readmitted 12/25-12/28 with seizures and acute kidney injury discharged to SNF on hospice care.
Preexisting Conditions: Obesity, TBI, quadriplegia secondary to GSW; COPD; seizures; gout; neurogenic bowel and bladder; major depressive disorder; dextroscollosis; DM
Allergies: NKA
Diagnostic Lab Data: 12/25 Dilantin level low 9.2 and drug screen positive for barbituates 12/28: glucose 149; BUN 28; Cr 3.39; Bun/Cr ratio 7.9; GFR 19; Na 150; chloride 114 12/27: Potassium 6.2 down within normal range on 12/28 4.2
CDC Split Type:

Write-up: Death within thirty days of vaccine. Multiple co-morbidities and placed on hospice 12/28/20.


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