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

This is VAERS ID 1143912

Case Details

VAERS ID: 1143912 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Ohio  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1802068 / 1 UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Angiogram, Bilevel positive airway pressure, Blood culture, Brain natriuretic peptide increased, Bronchoscopy, Cardiac failure acute, Chest X-ray, Computerised tomogram abnormal, Computerised tomogram head, Condition aggravated, Culture urine, Death, Diarrhoea, Differential white blood cell count, Dyspnoea, Fibrin D dimer, Full blood count, Hypotension, Intensive care, International normalised ratio, Lipase, Mechanical ventilation, Metabolic function test, Nausea, Pneumonitis, Polyuria, Red blood cell sedimentation rate, SARS-CoV-2 antibody test, SARS-CoV-2 test, Scan with contrast, Troponin
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Retroperitoneal fibrosis (broad), Pseudomembranous colitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (narrow), Hypersensitivity (broad), Noninfectious diarrhoea (narrow), Tubulointerstitial diseases (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad), Hypokalaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-29
   Days after onset: 18
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 18 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: amiodarone, aspirin, atorvastatin, Entresto, escitalopram, ferrous sulfate, gabapentin, chewable multivitamin, niacin controlled release, omeprazole, warfarin, tramadol, tempazepam
Current Illness: no acute illnesses
Preexisting Conditions: dual chamber ICD placement 2-2021; Aortic valve replacement (long time ago), hyperlipidemia, depression, rEFHF, pAF, osteoarthritis, hypertension
Allergies: nkda
Diagnostic Lab Data: Lots. CBC with autodifferential and bmp every day from 3-11-21 to 3-28-21 In addition: 3-11-21: CXR, CT angiogram with contrast, COVID testing, , blood cultures, urine culture, ddimer, esr, cmp, bnp, lipase, troponin; INR 3-12-21: respiratory pathogen testing; repeat COVID PCR testing; INR, iron studeis, CMP 3-15-21: CT head 3-19-21: COVID IGG testing and PCR repeat; blood cultures; CXR, abdominal XR 3-20-21: blood cultures; CXR 3-21-21: CXR 3-22-21 - bronchoscopy with BAL; pre and post intubation CXR 3-23-21: blood cultures; CXR; CT angiogram chest, CTAP 3-24-21: CXR 3-25-21: CXR 3-26-21: CXR 3-27-21: urine and blood cultures; CXR 3-28-21: CXR
CDC Split Type:

Write-up: Suspected pneumonitis. Patient presented on day following vaccination as shortness of breath, nausea, and diarrhea were not abating with home management. They had started later in the day after the vaccination. At ER admission - SpO2 = 80% room air. Nasal cannula was applied and SpO2 recovered quickly. BNP was elevated so acute exacerbation of heart failure was suspected and treated. However, patient did not improve with diuresis. Viral workup and bacterial cause workup negative. No acute cardiac events discovered. Patient continued to decline. Transferred to ICU on 3-19-21 to use BiPAP with 65% FiO2 and able to take breaks to 15L nasal cannula. Borderline blood pressures at this time. Infectious disease, pulmonology, cardiology, nephrology, and critical care anesthesia services evaluated and ruled out multiple possible diagnoses and patient continued to decline. Diagnostic bronchoscopy on 3-22-21 with BAL lead to patient ventilator dependent with profound hypotension. Aggressive ICU management ensued. Bronchoscopy very clean with no real secretions - in line with CT evidence of pneumonitis. Despite aggressive care and maximized pressor support, patient expired on 3-29-21 when family chose to withdraw care as blood pressure declined again.

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