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

This is VAERS ID 1108492



Case Details

VAERS ID: 1108492 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Foreign  
Vaccinated:2021-01-20
Onset:2021-03-01
   Days after vaccination:40
Submitted: 0000-00-00
Entered: 2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Other       Purchased by: ?
Symptoms: Renal vasculitis, SARS-CoV-2 test
SMQs:, Vasculitis (narrow), Renovascular disorders (narrow), Immune-mediated/autoimmune disorders (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-07
   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:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Blood pressure high
Allergies:
Diagnostic Lab Data: Test Name: COVID-19 virus test; Result Unstructured Data: Test Result:No - Negative COVID-19 test
CDC Split Type: GBPFIZER INC2021258797

Write-up: Renal vasculitis; This is a spontaneous report from a contactable consumer. This is a report received from the Regulatory Authority. Regulatory authority report number GB-MHRA-WEBCOVID-202103081226406770, Safety Report Unique Identifier GB-MHRA-ADR 24899397. A male patient of an unspecified age received the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 MRNA VACCINE) via an unspecified route of administration, on 20Jan2021, at single dose for Covid-19 immunisation. Medical history included hypertension, Patient has not had symptoms associated with COVID-19 Patient is not enrolled in clinical trial. The patient experienced renal vasculitis described as , painful joints 2 weeks after vaccine, 4 weeks after rash on legs swollen hands and feet all on an unspecified date. The patient died from renal vasculitis on 07Mar2021. The patient underwent lab tests and procedures which included sars-cov-2 test: negative covid-19 test on unknown date. It was not reported if an autopsy was performed. The clinical course was reported as: Painful joints 2 weeks after vaccine. 4 weeks after rash on legs swollen hands and feet Patient has not tested positive for COVID-19 since having the vaccine. No follow-up attempts are possible; information about lot/batch number cannot be obtained.; Reported Cause(s) of Death: Renal vasculitis


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