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From the 10/8/2021 release of VAERS data:

This is VAERS ID 1152971



Case Details

VAERS ID: 1152971 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Foreign  
Vaccinated:2021-02-11
Onset:2021-02-12
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 30042721 / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Fatigue, Hypophagia, Nausea, SARS-CoV-2 test, Vomiting
SMQs:, Acute pancreatitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-18
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: FOSINOPRIL; METFORMINE [METFORMIN]; NITROFURANTOINE; COMBIGAN; OXAZEPAM; CLOPIDOGREL; NORTRIPTYLINE; CALCIUM CARBONATE; AMLODIPINE; PARACETAMOL; HYDROXOCOBALAMINE; CLOBETASOL
Current Illness: Alzheimer''s disease; Type 2 diabetes mellitus
Preexisting Conditions: Medical History/Concurrent Conditions: Cerebrovascular accident; Multiple myeloma; Urinary tract infection
Allergies:
Diagnostic Lab Data: Test Date: 20210212; Test Name: corona sneltest; Test Result: Negative ; Result Unstructured Data: Negative
CDC Split Type: NLMODERNATX, INC.MOD20210

Write-up: A Regulatory Authority report was received from a pharmacist for a 78 year old female patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and who experienced fatigue, nausea, vomiting, and decreased oral intake (hypophagia). The patient''s medical history included cerebrovascular accident, type 2 diabetes mellitus, urinary tract infection, alzheimer''s dementia, and plasma cell myeloma. The concomitant medications included clopidogrel, nortriptyline, calcium carbonate, amlodipine, paracetamol, hydroxocobalamine, clobetasol, fosinopril, metformine [metformin], nitrofurantoine, brimonidine tartrate timolol maleate and oxazepam. On 11-Feb-2021, the patient received their first of two planned doses of mRNA-1273 (Lot number: 30042721) intramuscularly for prophylaxis of COVID-19 infection. On 12-Feb-2021, one day after receiving the vaccine, the patient experienced fatigue, nausea and vomiting. A SARS-CoV-2 test was performed which was negative. On a date not reported, the patient experienced decreased oral intake. The patient died on 18 Feb 2021. The cause of death was reported as nausea and decreased oral intake. No autopsy was performed. Treatment information was not applicable. Action taken with mRNA-1273 was not applicable. The outcome of the events nausea, vomiting, and decreased oral intake was fatal and the outcome for the event of fatigue was unknown. On 11Mar2021, follow up information was received which provided cause of death as decreased oral intake with no autopsy performed. A SARS-CoV-2 test was performed on 12Feb2021 which was negative.; Reporter''s Comments: Based on the current available information and temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded. However, the patient''s comorbidities may confound causality assessment. This case concerns a 78-year-old female who experienced serious unexpected events of fatigue, nausea, vomiting. The events occurred 2 days after the first dose of mRNA-1273. Treatment not reported. Event outcomes fatal. As above, a causal relationship cannot be excluded.


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