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

This is VAERS ID 1113080



Case Details

VAERS ID: 1113080 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Foreign  
Vaccinated:2021-01-21
Onset:2021-01-26
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ6788 / 1 LA / OT

Administered by: Other       Purchased by: ?
Symptoms: Body temperature, COVID-19, Oxygen saturation, SARS-CoV-2 test
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-18
   Days after onset: 23
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: COVID-19; Hip prosthesis user
Allergies:
Diagnostic Lab Data: Test Date: 20210126; Test Name: body temperature; Result Unstructured Data: Test Result:fever; Test Date: 20210126; Test Name: oxygen desaturation; Result Unstructured Data: Test Result:oxygen desaturation; Test Date: 20210126; Test Name: COVID-19 Testing; Result Unstructured Data: Test Result:aggravated COVID-19
CDC Split Type: FRPFIZER INC2021272392

Write-up: COVID-19 aggravated; This is a spontaneous report from a contactable physician downloaded from the Regulatory Authority FR-AFSSAPS-MP20210365. An 89-year-old male patient received first dose of bnt162b2 (COMIRNATY, Batch/Lot Number: EJ6788), intramuscular, in Arm Left on 21Jan2021 at single dose (reported as 1 DF) for covid-19 immunisation. Medical history included Hip prosthesis user and COVID-19. The patient''s concomitant medications were not reported. The patient experienced covid-19 aggravated on 26Jan2021, serious due to resulted in death. Therapeutic measures were taken as a result of covid-19 aggravated (covid-19). The patient died on 18Feb2021. An autopsy was not performed. The clinical course was reported as follows: Reporting via national website from a healthcare professional. Patient considered to be at risk of developing severe COVID-19. The patient had history of COVID-19. Testing was done on 26Jan2021. Course of the events: The patient was vaccinated in the framework of anti-COVID-19 vaccination plan. The first injection was performed with COVID-19 mRNA Vaccine (nucleoside modified) (COMIRNATY), lot #EJ6788 by intramuscular route in the left arm on 21Jan2021. On 26Jan2021, the patient was diagnosed with aggravated COVID-19 with fever and oxygen desaturation. On 03Feb2021, oxygen (unspecified trade name) therapy and IV fluids were given. From 09Feb2021, the patient presented with appetite loss, refusal of feeding and urinary retention. On 18Feb2021, the patient died. The conclusion was aggravated COVID-19 leading to death 28 days following vaccination. No other information was available. No FU attempts possible. No further information expected.; Reported Cause(s) of Death: COVID-19 aggravated


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