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From the 9/10/2021 release of VAERS data:

This is VAERS ID 1126863



Case Details

VAERS ID: 1126863 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Virginia  
Vaccinated:2021-03-08
Onset:2021-03-08
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805022 / UNK RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Aphasia, Bladder mass, Death, Gallbladder mass, Hydronephrosis, Hypoxia, Intensive care, Mini-tracheostomy, Mobility decreased, Pulmonary oedema, Pulseless electrical activity, Respiratory tract oedema, Vaccination complication
SMQs:, Cardiac failure (narrow), Asthma/bronchospasm (broad), Retroperitoneal fibrosis (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Parkinson-like events (broad), Acute central respiratory depression (broad), Gallbladder related disorders (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Eosinophilic pneumonia (broad), Cardiac arrhythmia terms, nonspecific (narrow), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Hypersensitivity (broad), Respiratory failure (broad), Tendinopathies and ligament disorders (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-10
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: acetaminophen (TYLENOL) 325 MG suppository acetic acid (VOSOL) 2 % otic solution amLODIPine (NORVASC) 2.5 MG tablet Cholecalciferol (VITAMIN D) 125 MCG (5000 UT) Cap ciprofloxacin-dexamethasone (CIPRODEX) otic suspension Cyanocobalamin (B-1
Current Illness: CVA Chronic Aspiration Chronic PNA
Preexisting Conditions: Chronic Aspiration Chronic PNA
Allergies: None on file
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was vaccinated in her home (COVID J&J) on 3/8. Vaccinator obtained consent and confirmed throughout the process that patient as at baseline since patient was nonverbal and bedbound. Later that same day she experienced an emergency and was take to the hospital and subsequently admitted to ICU. She died on 3/10, family present, on comfort care. Per HPI, "Patient is a 85 y.o. female with advanced dementia (non verbal, wheelchair bound at baseline), chronic aspiration, recurrent UTIs, voiding dysfunction currently self-straight cathing, has suspicious bladder and gallbladder masses (being worked up), has right sided hydronephrosis, BIBEMS for acute hypoxemia, difficult to bag en route, ED had difficulty intubating and so performed cricothroidotomy. Patient had brief PEA arrest due to hypoxia. ED provider noted "excessive pulmonary edema in airway, unfavorable anatomy, and airway swelling." Suspected insult stemming from J&J COVID vaccination reaction.


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