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This is VAERS ID 1041211

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History of Changes from the VAERS Wayback Machine

First Appeared on 3/5/2021

VAERS ID: 1041211
VAERS Form:2
Age:63.0
Sex:Male
Location:Missouri
Vaccinated:2020-12-31
Onset:2021-01-22
Submitted:0000-00-00
Entered:2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 UN / IM

Administered by: Private      Purchased by: ??
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, C-reactive protein increased, Coagulopathy, Hepatitis, International normalised ratio increased, Prothrombin time prolonged, Pyrexia, Red blood cell sedimentation rate increased, Systemic inflammatory response syndrome, Blood alkaline phosphatase increased, Interleukin level increased, SARS-CoV-2 antibody test positive, SARS-CoV-2 antibody test

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 9     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Aspirin, amlodipine, multivitamin, lisinopril, Crestor.
Current Illness: None
Preexisting Conditions: Hypertension, hyperlipidemia.
Allergies: NKDA
Diagnostic Lab Data: Most notable for peak ALT 343, AST 241, alkaline phosphatase 121. on 2/15/21. INR 1.70 and PT 19.5 on 2/11/21. ESR $g 140 and CRP 15.6 (elevated) on 2/10/21. SARS-COV-2 IgG negative, IgM positive, and IL-6 at 63 (elevated) on 2/16/21.
CDC 'Split Type':

Write-up: Patient is meeting diagnostic criteria for multisystem inflammatory syndrome post-vaccination. He received his 1st Moderna COVID vaccination on 12/31/2020 (037K20A) and his second COVID vaccination on 2/5/21 (029L20A). He began developing high grade fevers on 1/22/21 and was admitted to our facility on 2/8/21 due to "fever of unknown etiology" associated with hepatitis and coagulopathy on laboratory studies. He underwent an extensive evaluation which failed to reveal any other infectious, rheumatologic, or hematologic explanation for his clinical syndrome. He was ultimately discharged to outpatient care with ongoing supportive care for his fevers. His liver associated enzymes were improving at discharge.


Changed on 5/7/2021

VAERS ID: 1041211 Before After
VAERS Form:2
Age:63.0
Sex:Male
Location:Missouri
Vaccinated:2020-12-31
Onset:2021-01-22
Submitted:0000-00-00
Entered:2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 UN / IM

Administered by: Private      Purchased by: ??
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, C-reactive protein increased, Coagulopathy, Hepatitis, International normalised ratio increased, Prothrombin time prolonged, Pyrexia, Red blood cell sedimentation rate increased, Systemic inflammatory response syndrome, Blood alkaline phosphatase increased, Interleukin level increased, SARS-CoV-2 antibody test positive, SARS-CoV-2 antibody test

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 9     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Aspirin, amlodipine, multivitamin, lisinopril, Crestor.
Current Illness: None
Preexisting Conditions: Hypertension, hyperlipidemia.
Allergies: NKDA NKDA
Diagnostic Lab Data: Most notable for peak ALT 343, AST 241, alkaline phosphatase 121. on 2/15/21. INR 1.70 and PT 19.5 on 2/11/21. ESR $g 140 and CRP 15.6 (elevated) on 2/10/21. SARS-COV-2 IgG negative, IgM positive, and IL-6 at 63 (elevated) on 2/16/21.
CDC 'Split Type':

Write-up: Patient is meeting diagnostic criteria for multisystem inflammatory syndrome post-vaccination. He received his 1st Moderna COVID vaccination on 12/31/2020 (037K20A) and his second COVID vaccination on 2/5/21 (029L20A). He began developing high grade fevers on 1/22/21 and was admitted to our facility on 2/8/21 due to "fever of unknown etiology" associated with hepatitis and coagulopathy on laboratory studies. He underwent an extensive evaluation which failed to reveal any other infectious, rheumatologic, or hematologic explanation for his clinical syndrome. He was ultimately discharged to outpatient care with ongoing supportive care for his fevers. His liver associated enzymes were improving at discharge.


Changed on 5/21/2021

VAERS ID: 1041211 Before After
VAERS Form:2
Age:63.0
Sex:Male
Location:Missouri
Vaccinated:2020-12-31
Onset:2021-01-22
Submitted:0000-00-00
Entered:2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 UN / IM

Administered by: Private      Purchased by: ??
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, C-reactive protein increased, Coagulopathy, Hepatitis, International normalised ratio increased, Prothrombin time prolonged, Pyrexia, Red blood cell sedimentation rate increased, Systemic inflammatory response syndrome, Blood alkaline phosphatase increased, Interleukin level increased, SARS-CoV-2 antibody test positive, SARS-CoV-2 antibody test

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 9     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Aspirin, amlodipine, multivitamin, lisinopril, Crestor.
Current Illness: None
Preexisting Conditions: Hypertension, hyperlipidemia.
Allergies: NKDA NKDA
Diagnostic Lab Data: Most notable for peak ALT 343, AST 241, alkaline phosphatase 121. on 2/15/21. INR 1.70 and PT 19.5 on 2/11/21. ESR $g 140 and CRP 15.6 (elevated) on 2/10/21. SARS-COV-2 IgG negative, IgM positive, and IL-6 at 63 (elevated) on 2/16/21.
CDC 'Split Type':

Write-up: Patient is meeting diagnostic criteria for multisystem inflammatory syndrome post-vaccination. He received his 1st Moderna COVID vaccination on 12/31/2020 (037K20A) and his second COVID vaccination on 2/5/21 (029L20A). He began developing high grade fevers on 1/22/21 and was admitted to our facility on 2/8/21 due to "fever of unknown etiology" associated with hepatitis and coagulopathy on laboratory studies. He underwent an extensive evaluation which failed to reveal any other infectious, rheumatologic, or hematologic explanation for his clinical syndrome. He was ultimately discharged to outpatient care with ongoing supportive care for his fevers. His liver associated enzymes were improving at discharge.


Changed on 6/4/2021

VAERS ID: 1041211 Before After
VAERS Form:2
Age:63.0
Sex:Male
Location:Missouri
Vaccinated:2020-12-31
Onset:2021-01-22
Submitted:0000-00-00
Entered:2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 UN / IM

Administered by: Private      Purchased by: ??
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, C-reactive protein increased, Coagulopathy, Hepatitis, International normalised ratio increased, Prothrombin time prolonged, Pyrexia, Red blood cell sedimentation rate increased, Systemic inflammatory response syndrome, Blood alkaline phosphatase increased, Interleukin level increased, SARS-CoV-2 antibody test positive, SARS-CoV-2 antibody test

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 9     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Aspirin, amlodipine, multivitamin, lisinopril, Crestor.
Current Illness: None
Preexisting Conditions: Hypertension, hyperlipidemia.
Allergies: NKDA
Diagnostic Lab Data: Most notable for peak ALT 343, AST 241, alkaline phosphatase 121. on 2/15/21. INR 1.70 and PT 19.5 on 2/11/21. ESR $g 140 and CRP 15.6 (elevated) on 2/10/21. SARS-COV-2 IgG negative, IgM positive, and IL-6 at 63 (elevated) on 2/16/21.
CDC 'Split Type':

Write-up: Patient is meeting diagnostic criteria for multisystem inflammatory syndrome post-vaccination. He received his 1st Moderna COVID vaccination on 12/31/2020 (037K20A) and his second COVID vaccination on 2/5/21 (029L20A). He began developing high grade fevers on 1/22/21 and was admitted to our facility on 2/8/21 due to "fever of unknown etiology" associated with hepatitis and coagulopathy on laboratory studies. He underwent an extensive evaluation which failed to reveal any other infectious, rheumatologic, or hematologic explanation for his clinical syndrome. He was ultimately discharged to outpatient care with ongoing supportive care for his fevers. His liver associated enzymes were improving at discharge.


Changed on 7/30/2021

VAERS ID: 1041211 Before After
VAERS Form:2
Age:63.0
Sex:Male
Location:Missouri
Vaccinated:2020-12-31
Onset:2021-01-22
Submitted:0000-00-00
Entered:2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 UN / IM

Administered by: Private      Purchased by: ??
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, C-reactive protein increased, Coagulopathy, Hepatitis, International normalised ratio increased, Prothrombin time prolonged, Pyrexia, Red blood cell sedimentation rate increased, Systemic inflammatory response syndrome, Blood alkaline phosphatase increased, Interleukin level increased, SARS-CoV-2 antibody test positive, SARS-CoV-2 antibody test

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 9     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Aspirin, amlodipine, multivitamin, lisinopril, Crestor.
Current Illness: None
Preexisting Conditions: Hypertension, hyperlipidemia.
Allergies: NKDA
Diagnostic Lab Data: Most notable for peak ALT 343, AST 241, alkaline phosphatase 121. on 2/15/21. INR 1.70 and PT 19.5 on 2/11/21. ESR $g 140 and CRP 15.6 (elevated) on 2/10/21. SARS-COV-2 IgG negative, IgM positive, and IL-6 at 63 (elevated) on 2/16/21.
CDC 'Split Type':

Write-up: Patient is meeting diagnostic criteria for multisystem inflammatory syndrome post-vaccination. He received his 1st Moderna COVID vaccination on 12/31/2020 (037K20A) and his second COVID vaccination on 2/5/21 (029L20A). He began developing high grade fevers on 1/22/21 and was admitted to our facility on 2/8/21 due to "fever of unknown etiology" associated with hepatitis and coagulopathy on laboratory studies. He underwent an extensive evaluation which failed to reveal any other infectious, rheumatologic, or hematologic explanation for his clinical syndrome. He was ultimately discharged to outpatient care with ongoing supportive care for his fevers. His liver associated enzymes were improving at discharge.

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