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

This is VAERS ID 1057750



Case Details

VAERS ID: 1057750 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-01-20
Onset:2021-02-08
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 RA / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Blood test, COVID-19 pneumonia, Chest pain, Decreased appetite, Diarrhoea, Headache, Influenza virus test negative, Malaise, Myalgia, Viral test negative
SMQs:, Rhabdomyolysis/myopathy (broad), Pseudomembranous colitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Noninfectious diarrhoea (narrow), Tendinopathies and ligament disorders (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-14
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: PROCARDIA [NIFEDIPINE]; LOFIBRA [FENOFIBRATE]
Current Illness: Blood pressure high
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Test Date: 20210206; Test Name: Blood test; Result Unstructured Data: Blood test; Test Date: 20210206; Test Name: Influenza virus test negative; Test Result: Negative ; Result Unstructured Data: influenza virus test; Test Date: 20210206; Test Name: COVID-19 test; Test Result: Negative ; Result Unstructured Data: COVID-19 test
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Started feeling unwell; Headaches; Body aches; Chest pain; Didn''t had wishes to eat; Diarrhea; COVID-19 pneumonia; A spontaneous report was received from a consumer concerning a 69-year-old male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced COVID-19 pneumonia, feeling unwell, headaches, body aches, chest pain, decreased appetite and diarrhea The patient''s medical history high blood pressure which was controlled with medication. Concomitant product use included nifedipine and fenofibrate. On 20-JAN-2021, approximately a week and a half or two prior to the onset of the symptoms, the patient received their first of two planned doses of mRNA-1273 (Batch number 030L20A) intramuscularly in the right arm for prophylaxis of COVID-19 infection. A week and a half or two later the patient stated feeling unwell, headaches, body aches, chest pain, decreased appetite and diarrhea for which patient was hospitalized on 06-FEB-2021. Since everything seemed to be fine the patient was discharged on an unknown date in FEB-2021 however, patient''s family was not notified that it was a late reaction to the vaccine''s first dose. Later, due to shortness of breath he was hospitalized again on 08-FEB-2021 and was diagnosed for pneumonia and was intubated on the same day. Due to COVID-19 situation patient''s family could not be in the facilities and that there wasn''t any follow up of the patient given to the family, so family did not have much information. During the first hospitalization(06-FEB-2021) the patient had a blood test which showed a normal result and was tested for COVID-19 and Influenza, both were negative. During second hospitalization (08-FEB-2021) the hospital said that the patient was stable. The patient''s family did not know the results of the tests conducted at the time. The action taken with the vaccine in response to the events is not applicable. The outcome of COVID-19 pneumonia was fatal. The patient died on 14 Feb 2021 The cause of death was reported as COVID-19 related pneumonia. The autopsy was not done.; Reporter''s Comments: Very limited information regarding this event has been provided at this time. The cause of death was reported as COVID-19 related pneumonia. Based on the current available information and the mechanism of action of mRNA-1237 vaccine, the events are assessed as unlikely related. Further information has been requested.; Reported Cause(s) of Death: COVID-19 pneumonia


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