National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

From the 10/8/2021 release of VAERS data:

This is VAERS ID 1103813



Case Details

VAERS ID: 1103813 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Female  
Location: New York  
Vaccinated:2021-02-28
Onset:2021-03-02
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 001121A / 1 UN / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Abdominal distension, Acute kidney injury, Chest pain, Death, Dehydration, Dyspnoea, Echocardiogram normal, Electrocardiogram normal, Fatigue, Haemoglobin normal, Influenza virus test negative, International normalised ratio normal, Nausea, Pain, Platelet count normal, Prothrombin time normal, Renal failure, SARS-CoV-2 test negative, Ultrasound kidney normal, Urine analysis normal, Vomiting, White blood cell count normal
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-13
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Ibrance, vit d, femara, losartan, hctz
Current Illness: HTN, Mild COPD, Breast cancer
Preexisting Conditions: as above
Allergies: None
Diagnostic Lab Data: as above. pt/inr normal, no PE, echo and ekg normal. normal wbc, hgb abd platelets. no new medications to cause renal failure. no imp with ivf. covid neg, flu neg, ua normal. renal us normal.
CDC Split Type:

Write-up: Pt was vaccinated on 2/28 and on 3/2 began to experience worsened sob from baseline, development of sternal chest pain, abdominal bloating, nausea and fatigue. She presented to the hospital on 3/9 c/o intractable pain and nausea/vomiting that was worsening. Imaging revealed no change in her cancer from same imaging in jan 2021. PE ruled out. No sepsis. She had acute kidney injury/dehydration. started on ivf. renal imaging normal. echo normal. ekg normal. she rapidly progressed to anuric renal failure and died 3/13/2021. oncology ruled out tumor lysis. she was not felt to be a candidate for dialysis.


New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1103813

Government Disclaimer on use of this data


Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166