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

This is VAERS ID 1056972



Case Details

VAERS ID: 1056972 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Maine  
Vaccinated:2021-01-29
Onset:2021-02-04
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Abdominal pain, Acute myocardial infarction, Antiphospholipid syndrome, Atrial fibrillation, Biliary dilatation, Cerebrovascular accident, Diarrhoea, Dysphagia, Electrocardiogram QT prolonged, Encephalopathy, Endoscopy, Gastrointestinal oedema, Hepatic cirrhosis, Imaging procedure, Intestinal angioedema, Intestinal mass, Intracranial mass, Laboratory test, Leukocytosis, Malaise, Oesophageal varices haemorrhage, Peritonitis bacterial, Supraventricular tachycardia, Thrombosis
SMQs:, Torsade de pointes/QT prolongation (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Acute pancreatitis (broad), Angioedema (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Conduction defects (narrow), Supraventricular tachyarrhythmias (narrow), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Retroperitoneal fibrosis (broad), Torsade de pointes, shock-associated conditions (narrow), Pseudomembranous colitis (broad), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Gastrointestinal perforation (narrow), Gastrointestinal haemorrhage (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Thrombophlebitis (broad), Biliary tract disorders (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Noninfectious meningitis (broad), Gastrointestinal nonspecific inflammation (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Pregnancy, labour and delivery complications and risk factors (excl abortions and stillbirth) (broad), Chronic kidney disease (broad), Hypersensitivity (narrow), Noninfectious diarrhoea (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-27
   Days after onset: 23
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Acetaminophen
Current Illness:
Preexisting Conditions: Depression Hyperlipidemia Anxiety disorder Elevated BP without diagnosis of hypertension Alcohol abuse Osteopenia Tubular adenoma of colon Serrated adenoma of colon Cyst of left breast
Allergies: Ampicillin-nausea
Diagnostic Lab Data: Pt. has had multiple lab tests, imaging studies, endoscopic procedures. Too numerous to list here. Current Hospital diagnoses as of 02/26/2021 Hospital SVT (supraventricular tachycardia) Thrombus Acute encephalopathy Dysphagia, unspecified Non-ST elevation (NSTEMI) myocardial infarction Prolonged Q-T interval on ECG Leukocytosis A-fib Common bile duct dilation Duodenal mass Cirrhosis Small bowel edema Stroke Bleeding esophageal varices SBP (spontaneous bacterial peritonitis) Catastrophic antiphospholipid syndrome
CDC Split Type:

Write-up: 5-6 days after receiving first Moderna covid vaccine pt. began not feeling well. On 02/10/2021 she saw a provider in an office for eval of abdominal pain and diarrhea and sent home. On 02/15/2021 she presented to a local ED with continuing symptoms, transferred to Medical Center. She is currently an inpatient there with a diagnosis of multiple blood clots in abdomen and brain and antiphospholipid syndrome.


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