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This is VAERS ID 1153962

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History of Changes from the VAERS Wayback Machine

First Appeared on 4/30/2021

VAERS ID: 1153962
VAERS Form:2
Age:
Sex:Male
Location:Unknown
Vaccinated:2021-03-12
Onset:2021-03-15
Submitted:0000-00-00
Entered:2021-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038A21A / 1 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Chest pain, Myocarditis, SARS-CoV-2 test, SARS-CoV-2 antibody test

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: COVID-19 (Reporter reported that patient had COVID-19 in Mar 2020 was exposed and may have had it a second time on 11/2020); COVID-19
Allergies:
Diagnostic Lab Data: Test Name: COVID- 19 antibody; Test Result: Positive ; Result Unstructured Data: about 561; Test Date: 202003; Test Name: COVID-19 TEST; Test Result: Positive ; Result Unstructured Data: The patient had covid 3/2020 and was exposed and may have had it a second time on 11/2020
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: Acute myocarditis; Chest pain; A spontaneous report was received from a physician concerning (patient age: unknown) male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced chest pain, acute myocarditis (myocarditis). The patient''s medical history included COVID-19 in Mar 2020 and was exposed and may have had it a second time in Nov 2020. Concomitant medications were not provided. On 12 Mar 2021, prior to the onset of the event, the patient received their first of two planned doses of mRNA-1273 (Lot number: 038A21A) intramuscularly for prophylaxis of COVID-19 infection. On 15 Mar 2021, the patient developed chest pain and was admitted to the hospital. The patient underwent cardiac catheterization, echocardiogram and cardiac MRI (magnetic resonance imaging). Results of the echocardiogram and cardiac MRI were not provided. The final diagnosis of the patient was acute myocarditis. COVID antibodies were positive, about 561 for the patient. The events chest pain and acute myocarditis lead to hospitalization. Treatment activities for the events were unknown. Action taken with mRNA-1273 in response to the events was unknown. The outcome of events, experienced chest pain and acute myocarditis, was unknown.; 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.


Changed on 5/7/2021

VAERS ID: 1153962 Before After
VAERS Form:2
Age:
Sex:Male
Location:Unknown
Vaccinated:2021-03-12
Onset:2021-03-15
Submitted:0000-00-00
Entered:2021-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038A21A / 1 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Chest pain, Myocarditis, SARS-CoV-2 test, SARS-CoV-2 antibody test

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: COVID-19 (Reporter reported that patient had COVID-19 in Mar 2020 was exposed and may have had it a second time on 11/2020); COVID-19
Allergies:
Diagnostic Lab Data: Test Name: COVID- 19 antibody; Test Result: Positive ; Result Unstructured Data: about 561; Test Date: 202003; Test Name: COVID-19 TEST; Test Result: Positive ; Result Unstructured Data: The patient had covid 3/2020 and was exposed and may have had it a second time on 11/2020
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: Acute myocarditis; Chest pain; A spontaneous report was received from a physician concerning (patient age: unknown) male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced chest pain, acute myocarditis (myocarditis). The patient''s medical history included COVID-19 in Mar 2020 and was exposed and may have had it a second time in Nov 2020. Concomitant medications were not provided. On 12 Mar 2021, prior to the onset of the event, the patient received their first of two planned doses of mRNA-1273 (Lot number: 038A21A) intramuscularly for prophylaxis of COVID-19 infection. On 15 Mar 2021, the patient developed chest pain and was admitted to the hospital. The patient underwent cardiac catheterization, echocardiogram and cardiac MRI (magnetic resonance imaging). Results of the echocardiogram and cardiac MRI were not provided. The final diagnosis of the patient was acute myocarditis. COVID antibodies were positive, about 561 for the patient. The events chest pain and acute myocarditis lead to hospitalization. Treatment activities for the events were unknown. Action taken with mRNA-1273 in response to the events was unknown. The outcome of events, experienced chest pain and acute myocarditis, was unknown.; 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.


Changed on 5/14/2021

VAERS ID: 1153962 Before After
VAERS Form:2
Age:
Sex:Male
Location:Unknown
Vaccinated:2021-03-12
Onset:2021-03-15
Submitted:0000-00-00
Entered:2021-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038A21A / 1 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Chest pain, Myocarditis, SARS-CoV-2 test, SARS-CoV-2 antibody test

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: COVID-19 (Reporter reported that patient had COVID-19 in Mar 2020 was exposed and may have had it a second time on 11/2020); COVID-19
Allergies:
Diagnostic Lab Data: Test Name: COVID- 19 antibody; Test Result: Positive ; Result Unstructured Data: about 561; Test Date: 202003; Test Name: COVID-19 TEST; Test Result: Positive ; Result Unstructured Data: The patient had covid 3/2020 and was exposed and may have had it a second time on 11/2020
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: Acute myocarditis; Chest pain; A spontaneous report was received from a physician concerning (patient age: unknown) male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced chest pain, acute myocarditis (myocarditis). The patient''s medical history included COVID-19 in Mar 2020 and was exposed and may have had it a second time in Nov 2020. Concomitant medications were not provided. On 12 Mar 2021, prior to the onset of the event, the patient received their first of two planned doses of mRNA-1273 (Lot number: 038A21A) intramuscularly for prophylaxis of COVID-19 infection. On 15 Mar 2021, the patient developed chest pain and was admitted to the hospital. The patient underwent cardiac catheterization, echocardiogram and cardiac MRI (magnetic resonance imaging). Results of the echocardiogram and cardiac MRI were not provided. The final diagnosis of the patient was acute myocarditis. COVID antibodies were positive, about 561 for the patient. The events chest pain and acute myocarditis lead to hospitalization. Treatment activities for the events were unknown. Action taken with mRNA-1273 in response to the events was unknown. The outcome of events, experienced chest pain and acute myocarditis, was unknown.; 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.

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