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This is VAERS ID 1086868

History of Changes from the VAERS Wayback Machine

First Appeared on 3/11/2021

VAERS ID: 1086868
VAERS Form:2
Age:72.0
Sex:Male
Location:Illinois
Vaccinated:2020-12-29
Onset:2021-01-17
Submitted:0000-00-00
Entered:2021-03-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K208 / 1 RA / OT

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Hypotension, Medical device site haemorrhage

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-27
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? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Surgical vascular shunt
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: Passed away; Severe hypotension; Hemodialysis shunt bleeding; A spontaneous report was received from other health professional concerning a 72 years old, male patient who experienced hypotension, removal and replacement of hemodialysis shunt (procedure), hemodialysis shunt bleeding and death. The patient''s medical history was not provided. Concomitant product use was not provided/unknown by the reporter. On 29-DEC-2020, the patient received their first of two planned doses of mRNA-1273 (Batch number [LOT/BATCH: 039K208] intramuscularly in the right arm for prophylaxis of COVID-19 infection. The patient was hospitalized for severe hypotension and Removal and Replacement of hemodialysis shunt from 17-JAN-2021 to 21-Jan-2021. On 26-01-2021 the patient was sent to hospital due to his hemodialysis shunt bleeding. On 27-01-2021, the patient passed away at the hospital . Treatment information was unknown. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 27 Jan 2021. The cause of death was unknown. Plans for an autopsy were unknown.; Reporter''s Comments: Very limited information regarding this event/s has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Unknown cause of death


Changed on 5/7/2021

VAERS ID: 1086868 Before After
VAERS Form:2
Age:72.0
Sex:Male
Location:Illinois
Vaccinated:2020-12-29
Onset:2021-01-17
Submitted:0000-00-00
Entered:2021-03-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K208 / 1 RA / OT

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Hypotension, Medical device site haemorrhage

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-27
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? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Surgical vascular shunt
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: Passed away; Severe hypotension; Hemodialysis shunt bleeding; A spontaneous report was received from other health professional concerning a 72 years old, male patient who experienced hypotension, removal and replacement of hemodialysis shunt (procedure), hemodialysis shunt bleeding and death. The patient''s medical history was not provided. Concomitant product use was not provided/unknown by the reporter. On 29-DEC-2020, the patient received their first of two planned doses of mRNA-1273 (Batch number [LOT/BATCH: 039K208] intramuscularly in the right arm for prophylaxis of COVID-19 infection. The patient was hospitalized for severe hypotension and Removal and Replacement of hemodialysis shunt from 17-JAN-2021 to 21-Jan-2021. On 26-01-2021 the patient was sent to hospital due to his hemodialysis shunt bleeding. On 27-01-2021, the patient passed away at the hospital . Treatment information was unknown. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 27 Jan 2021. The cause of death was unknown. Plans for an autopsy were unknown.; Reporter''s Comments: Very limited information regarding this event/s has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Unknown cause of death


Changed on 5/14/2021

VAERS ID: 1086868 Before After
VAERS Form:2
Age:72.0
Sex:Male
Location:Illinois
Vaccinated:2020-12-29
Onset:2021-01-17
Submitted:0000-00-00
Entered:2021-03-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K208 / 1 RA / OT

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Hypotension, Medical device site haemorrhage

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-27
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? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Surgical vascular shunt
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: Passed away; Severe hypotension; Hemodialysis shunt bleeding; A spontaneous report was received from other health professional concerning a 72 years old, male patient who experienced hypotension, removal and replacement of hemodialysis shunt (procedure), hemodialysis shunt bleeding and death. The patient''s medical history was not provided. Concomitant product use was not provided/unknown by the reporter. On 29-DEC-2020, the patient received their first of two planned doses of mRNA-1273 (Batch number [LOT/BATCH: 039K208] intramuscularly in the right arm for prophylaxis of COVID-19 infection. The patient was hospitalized for severe hypotension and Removal and Replacement of hemodialysis shunt from 17-JAN-2021 to 21-Jan-2021. On 26-01-2021 the patient was sent to hospital due to his hemodialysis shunt bleeding. On 27-01-2021, the patient passed away at the hospital . Treatment information was unknown. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 27 Jan 2021. The cause of death was unknown. Plans for an autopsy were unknown.; Reporter''s Comments: Very limited information regarding this event/s has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Unknown cause of death

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