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From the 10/15/2021 release of VAERS data:

This is VAERS ID 1168978



Case Details

VAERS ID: 1168978 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-01-28
Onset:2021-02-23
   Days after vaccination:26
Submitted: 0000-00-00
Entered: 2021-04-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 LA / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Ageusia, Chills, Fall, Headache, Hypertrophic cardiomyopathy, Myalgia, Nausea, Pain, Pyrexia
SMQs:, Rhabdomyolysis/myopathy (broad), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Taste and smell disorders (narrow), Anticholinergic syndrome (broad), Congenital, familial and genetic disorders (narrow), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (narrow), Eosinophilic pneumonia (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-06
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: ASPIRIN (E.C.)
Current Illness: Angiogram (Was told they had an excellent heart and no surgery was needed)
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: hypertrophic cardiomyopathy; he just suddenly fell; lost his sense of taste; excruciating pains all over his body; General body aches like he got ran over by a truck/excruciating pains all over his body; Headache; Chills; Fever; Nausea; Pain; Based on the current available information which includes a strong temporal association between the use of the product and onset of the events, and excluding other etiologies, causal relationship cannot be excluded..This spontaneous case was reported by a consumer and describes the occurrence of hypertrophic cardiomyopathy in a 74-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch nos. 030M20A and 007M20A) for COVID-19 vaccination. The patient''s past medical history included Angiogram (Was told they had an excellent heart and no surgery was needed) Concomitant products included acetylsalicylic (E.C.) for an unknown indication. On 28-Jan-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On 23-Feb-2021, received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) dosage was changed to 1 dosage form. On 23-Feb-2021, the patient experienced pain, headache, chills, fever and nausea. On 24-Feb-2021, the patient experienced lost his sense of taste, excruciating pains all over his body and myalgia (general body aches like he got ran over by a truck/excruciating pains all over his body). On 06-Mar-2021, the patient experienced hypertrophic cardiomyopathy (seriousness criterion death) and he just suddenly fell.. An autopsy was performed. Consumer reported on behalf of spouse. Ambulance was called and patient was pronounced dead. Awaiting toxicology report. Most recent FOLLOW-UP information incorporated above includes: On 26-Mar-2021: Major narrative update - outcome of events, additional events reported; Sender''s Comments: Based on the current available information which includes a strong temporal association between the use of the product and onset of pain, headache, chills, fever , nausea, loss of sense of taste, excruciating pains all over his body and myalgia and excluding other etiologies, causal relationship cannot be excluded. There is not enough details to assess the fatal event of hypertrophic cardiomyopathy and the administration of the product. Additional information has been requested.; Reported Cause(s) of Death: hypertrophic cardiomyopathy


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