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From the 11/26/2021 release of VAERS data:

This is VAERS ID 1127200

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Case Details

VAERS ID: 1127200 (history)  
Form: Version 2.0  
Age: 17.0  
Sex: Male  
Location: Wyoming  
Vaccinated:2021-03-19
Onset:2021-03-21
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: C-reactive protein increased, Ejection fraction decreased, Electrocardiogram ST segment elevation, Electrocardiogram abnormal, Inflammatory marker increased, Left ventricular dysfunction, Pyrexia, SARS-CoV-2 test negative, Troponin increased, Viral test
SMQs:, Cardiac failure (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Ferrous sulfate, Flonase, methotrexate, protonix
Current Illness:
Preexisting Conditions: HLA B27+ juvenile idiopathic arthritis, enthesitis-related subtype with sacroilitis well controlled on methotrexate (previously on Humira)
Allergies: none
Diagnostic Lab Data: Echo concerning for moderate LV dysfunction EF 44%, normalized the next day. - CRP 18 - COVID PCR negative, viral PCR negative. Other infectious workup pending.
CDC Split Type:

Write-up: one day of fever found to have elevated inflammatory markers, LV dysfunction (now resolved), elevated troponin and ST elevation in EKG concerning for myopericarditis. Admitted to hospital. No documented fever in hospital, no rash, no GI symptoms, no other criteria met for MIS-C. Unclear etiology of myopericaraditis.


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