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From the 5/7/2021 release of VAERS data:

This is VAERS ID 1122080



Case Details

VAERS ID: 1122080 (history)  
Form: Version 2.0  
Age: 46.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-03-12
Onset:2021-03-19
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Agonal respiration, Angiogram pulmonary abnormal, Areflexia, Blood lactic acid increased, Cardiac arrest, Complication associated with device, Corneal reflex decreased, Cyanosis, Death, Device malfunction, Disseminated intravascular coagulation, Dyspnoea, Fatigue, Intensive care, Loss of consciousness, Lung assist device therapy, Malaise, Metabolic acidosis, Mobility decreased, Presyncope, Pulmonary embolism, Pulseless electrical activity, Pupillary reflex impaired, Pyrexia, Respiratory acidosis, Resuscitation, Therapy cessation, Thrombectomy, Unresponsive to stimuli, Vena cava thrombosis
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Lactic acidosis (narrow), Peripheral neuropathy (broad), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Embolic and thrombotic events, venous (narrow), Parkinson-like events (broad), Thrombophlebitis (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Corneal disorders (narrow), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow), Tendinopathies and ligament disorders (broad), Medication errors (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-21
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Xulane birth control patch Prescribed prednisone the day prior to presentation
Current Illness: None
Preexisting Conditions: None
Allergies: Augmentin-itching
Diagnostic Lab Data: As above.
CDC Split Type:

Write-up: Patient''s received 2nd dose of Moderna vaccine Friday 3/12. Her husband reported she had not unexpected fatigue, malaise, and fever for 1 day but better after that. On Monday she began complaining of shortness of breath. This progressively worsened and she started having presyncopal episodes. On Saturday she was unable to come down the stairs in the house so husband planned to take her to the hospital but she stood up and passed out and woke up quickly. He decided to call EMS. By the time she presented to our hospital she was cyanotic and agonal breathing. On moving her from EMS stretcher to ED bed she had PEA cardiac arrest. She underwent mechanical device CPR with only brief (<1 min) ROSC x1. She at some point did have a shockable rhythm. Cath lab was notified and she was taken emergently to the cath lab with ongoing mechanical device CPR. Peripheral VA ECMO was placed after about 1.5 hours. Pulmonary angiogram was done which showed massive saddle PE with near complete obliteration of the right pulmonary tree and some filling defects in the left tree as well. At that time she had severe mixed respiratory and metabolic acidosis with a lactate of 24. She also had no gag or corneal reflex, minimally responsive pupils, and no response to noxious stimuli. Mechanical thrombectomy was attempted with some result. She was transferred to the SICU with increasing pressor requirement, and DIC. Ultimately, the venous catheter of the ECMO circuit malfunctioned thought to be secondary propagating IVC thrombosis. Family decided to withdraw care and she passed away.


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