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From the 4/30/2021 release of VAERS data:

This is VAERS ID 1144220



Case Details

VAERS ID: 1144220 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-03-12
Onset:2021-03-28
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-03-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Bacteraemia, Blood culture positive, Cardiac telemetry, Chest X-ray, Computerised tomogram abdomen, Computerised tomogram abnormal, Computerised tomogram head, Computerised tomogram thorax, Death, Endotracheal intubation, Full blood count, Metabolic function test, Pulseless electrical activity, Respiratory distress, Respiratory failure, Streptococcal sepsis, Streptococcus test positive, Ultrasound Doppler, Ultrasound abdomen
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-28
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 13 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Loratadine Coreg Protonix Flonase Synthroid Alprazolam
Current Illness:
Preexisting Conditions: Atrial fibrillation Hypertension Hypothyroidism Anxiety Allergic rhinitis
Allergies: Losartan Penicillin
Diagnostic Lab Data: Blood cultures Ct Brain 3/16 Ct thorax 3/16 Ct abdomen 3/16 Chest X-ray 3/16, 3/17, 3/18, 3/20, 3/22, 3/24, 3/25, 3/26, 3/27 Us LE venous duplex 3/16 US gallbladder 3/16 CBC, CMP daily from 3/16-3-27 Cardiac telemetry
CDC Split Type:

Write-up: Bacteremia - strep epidermidis, developed respiratory distress required intubation for hypercapnic respiratory failure. Developed PEA on 3/28 died.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1144220


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