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

This is VAERS ID 1063174



Case Details

VAERS ID: 1063174 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-10
Onset:2021-02-12
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9265 / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Alanine aminotransferase, Anion gap, Aspartate aminotransferase, Band neutrophil percentage, Basophil count, Basophil percentage, Blood albumin, Blood alkaline phosphatase, Blood bilirubin, Blood calcium, Blood chloride, Blood creatinine, Blood glucose, Blood potassium, Blood pressure fluctuation, Blood sodium, Blood thyroid stimulating hormone, Blood urea, Carbon dioxide, Death, EGFR gene mutation, Eosinophil count, Eosinophil percentage, Fluid retention, Free thyroxine index, Full blood count, Haematocrit, Haemoglobin, Heart rate irregular, Hypochromasia, Injection site rash, Laboratory test, Lymphocyte count, Lymphocyte percentage, Mean cell haemoglobin, Mean cell haemoglobin concentration, Mean cell volume, Monocyte count, Monocyte percentage, Neutrophil count, Neutrophil percentage, Peripheral swelling, Platelet count, Polychromasia, Protein total, Rash, Red blood cell analysis, Red blood cell burr cells present, Red blood cell count, Red blood cell microcytes, Red cell distribution width, Thyroid function test, Tri-iodothyronine, Urine output decreased, White blood cell count
SMQs:, Acute renal failure (broad), Cardiac failure (broad), Anaphylactic reaction (broad), Angioedema (broad), Neuroleptic malignant syndrome (broad), Retroperitoneal fibrosis (broad), Congenital, familial and genetic disorders (narrow), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypertension (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Chronic kidney disease (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-20
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: GENERAL CHEMISTRY Glucose Urea Nitrogen Creatinine Sodium Potassium Chloride Carbon Dioxide ANION GAP Calcium Protein, Total Albumin Bilirubin, Total Alkaline Phosphatase AST ALT eGFR, AA eGFR, Non-AA CBC/DIFF White Blood Cells Red Blood Cells Hemoglobin Hematocrit MCV MCH MCHC RDW Platelets % Neutrophils % Lymphocytes % Monocytes % EOSINOPHILS % Basophils # Neutrophils # Lymphocytes # Monocytes # Eosinophils # Basophils MANUAL DIFFERENTIAL % Segmented Neutro? % Band Neutrophils % Lymphocytes Manual % Monocytes Manual % Eosinophils Manual % Basophils Manual # Segmented Neutro? # Band Neutrophils #Lymphocytes Manual # Monocytes Manual # Eosinophils Manual # Basophils Manual ANC Manual Diff Platelet Estimate RBC Morphology Hypochromia Polychromasia Microcytes Ovalocytes Burr Cells Platelet Clumps FLUID HEMATOLOGY Red Blood Cells GENERAL ENDOCRINOLOGY Hemoglobin A1c THYROID FUNCTION TSH T3 UPTAKE THYROXINE FREE THYROXINE INDEX TUMOR MARKER PSA, Total MICRO GS ROUTINE CULTURE OTHERS TRIIODOTHYYRONINE 5 5/19/20 12:42 4 6/5/2020 14:00 3 10/23/2020 13:30 2 12/01/2020 16:00 1 2/17/2021 14:30 128 & 153 & 242 & 22 & 24 & 24 & <0.20 & <0.20 & <0.20 & 130 & 129 & 130 & 4.4 & 4.6 & 4.7 & 97 & 96 & 95 & 23 & 24 & 24 & 10 & 9 & 11 & 9.2 & 9.0 & 9.3 & 6.2 & 6.6 & 6.5 & 3.5 & 3.4 & 3.4 & 0.3 & 0.3 & 0.5 & 202 & 228 & 234 & 17 & 24 & 17 & 26 & 27 & 24 & $g60 $g60 $g60 $g60 $g60 $g60 5.3 & 7.4 & 6.1 & 28.2 & 4.91 & 4.93 & 4.54 & 4.73 & 11.0 & 11.0 & 11.3 & 11.8 & 34 & 34 & 34 & 37 & 68 & 68 & 74 & 78 & 22 & 22 & 25 & 25 & 33 & 33 & 34 & 32 & 25.8 & 27.1 & 26.4 & 20.7 & 175 & 185 & 152 & 190 & 75.5 75.9 12.1 12.2 11.0 10.6 0.9 0.7 0.5 0.6 4.00 & 5.60 & 0.60 0.90 0.60 0.80 0.00 0.10 0.00 0.00 80.9 96.1 0.0 0.0 11.4 1.0 5.7 2.9 1.0 0.0 1.0 0.0 4.95 27.09 0.00 0.00 0.70 0.28 0.35 0.82 0.06 0.00 0.06 0.00 4.95 27.09 NORMAL NORMAL See Below See Below SLIGHT MODERATE SLIGHT SLIGHT SLIGHT SLIGHT PRESENT PRESENT 4.91 & 4.93 & 4.54 & 4.73 &
CDC Split Type:

Write-up: Narrative: Patient received COVID/Pfizer #1 2/10/21 in L deltoid. (Patient home bound). On 2/12/21 reported left flank rash. 2/13 rash spread to entire abdomen/chest and UEs. Continued with fluctuations in BP/HR, fluid retention. On 2/16 labs ordered and Medrol dose pack. seen in home on 2/19 by MD - RUE swelling; diffuse rash over entire body; additional labs ordered (order to home infusion company). Patient passed in AM of 2/20/21. Reported no urine output the prior evening. Additional labs not performed due to death of patient prior to lab company arrival.


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