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This is VAERS ID 1169796

History of Changes from the VAERS Wayback Machine

First Appeared on 4/16/2021

VAERS ID: 1169796
VAERS Form:2
Age:81.0
Sex:Female
Location:New York
Vaccinated:2021-02-07
Onset:2021-02-21
Submitted:0000-00-00
Entered:2021-04-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA #039K20A / 1 UN / IM

Administered by: Public      Purchased by: ??
Symptoms: Blood culture negative, Blood lactate dehydrogenase increased, Bronchiectasis, Bronchoscopy, C-reactive protein increased, Chest X-ray abnormal, Computerised tomogram abnormal, Death, Diarrhoea, Dyspnoea, Fatigue, HIV test negative, Hypoxia, Interstitial lung disease, Lung infiltration, Neutrophil count increased, Pyrexia, Red blood cell count increased, White blood cell count increased, Nodule, Bacterial test positive, Antinuclear antibody positive, Acute interstitial pneumonitis, Endotracheal intubation, Respiratory syncytial virus test negative, Mycobacterium test negative, Legionella test, Fungal test negative, Influenza virus test negative, Procalcitonin normal, Lung opacity, SARS-CoV-2 test negative, SARS-CoV-2 antibody test

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2021-03-22
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 24     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Denied
Allergies: NKDA
Diagnostic Lab Data: - CT (3/3): moderate bilateral, predominantly dependent and peripheral/subpleural reticular and irregular groundglass and consolidative opacities, some with slightly rounded/nodular morphology; mild traction bronchiectasis; no pleural effusion or pneumothorax. - s/p bronchoscopy (3/9): BAL in lingula, 180 mL in / 90 mL out; mucous plugs present in return fluid. Labs/micro: - SARS/flu/RSV/BioFire neg, Legionella UAg neg, Bcxs neg - procalcitonin 0.05 (2/28) $g 0.09 (3/8) 2/28 SARS-CoV-2 semi-quantitative IgG (Kantaro assay) 4,447 AU/mL [ref range, < 5 AU/mL = negative to $g40 AU/mL = Strong positive "Interpretation: The Semi-Quantitative SARS-COV-2 IgG results of $g40 AU/mL confirm the presence of circulating IgG antibodies specific for SARS-CoV-2 at high levels. Corresponding serum titers range from 960 and rise to above 2880 with increasing numerical value. "] - 3/5 ANA 1:320, homogenous - 3/5 CRP 35 $g$g 150; LDH 830 - 3/9 BAL RBC 1.95K, WBC 473/68% polys, 26% macs, bacteria seen. SARS PCR neg. GS 1-9 polys, no orgs, cx usu resp flora, fungal cx neg, - AFB neg x6 - HIV neg; no known immunosuppressive predisposition to OIs like PCP or other fungi; serum CrAg/GM/Fungitell neg and sputum PCP DFA neg
CDC 'Split Type':

Write-up: 4/2020 presumed COVID-19 (not formally diagnosed, not hospitalized) 2/07/21 Moderna vaccine #1 (date per pt''s daughter) 2/21/21 onset SOB/DOE, fever 2/24/21 Seen at Urgent Care: RML crackles and infiltrate on CXR, given azithromycin and Augmentin 2/27/21 Presented to ED with progression of SOB/DOE, fatigue, diarrhea. Hypoxemic requiring low-flow NC, B/L basilar crackles noted; started on CTX/azithro (2/27-3/3) for presumed CAP 3/08/21 Required HFNC; first seen by me personally: diffuse, distinct velcro crackles, lower $g upper fields 3/12/21 Started on high-dose steroids without improvement; unable to wean from HFNC with progressively worsening hypoxemia; pt declined intubation. 03/22/21 Patient died in Palliative Care Unit Diagnosis: Interstitial lung disease of uncertain etiology, acute interstitial pneumonitis vs. undiagnosed connective tissue disease


Changed on 5/7/2021

VAERS ID: 1169796 Before After
VAERS Form:2
Age:81.0
Sex:Female
Location:New York
Vaccinated:2021-02-07
Onset:2021-02-21
Submitted:0000-00-00
Entered:2021-04-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA #039K20A / 1 UN / IM

Administered by: Public      Purchased by: ??
Symptoms: Blood culture negative, Blood lactate dehydrogenase increased, Bronchiectasis, Bronchoscopy, C-reactive protein increased, Chest X-ray abnormal, Computerised tomogram abnormal, Death, Diarrhoea, Dyspnoea, Fatigue, HIV test negative, Hypoxia, Interstitial lung disease, Lung infiltration, Neutrophil count increased, Pyrexia, Red blood cell count increased, White blood cell count increased, Nodule, Bacterial test positive, Antinuclear antibody positive, Acute interstitial pneumonitis, Endotracheal intubation, Respiratory syncytial virus test negative, Mycobacterium test negative, Legionella test, Fungal test negative, Influenza virus test negative, Procalcitonin normal, Lung opacity, SARS-CoV-2 test negative, SARS-CoV-2 antibody test

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2021-03-22
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 24     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Denied
Allergies: NKDA NKDA
Diagnostic Lab Data: - CT (3/3): moderate bilateral, predominantly dependent and peripheral/subpleural reticular and irregular groundglass and consolidative opacities, some with slightly rounded/nodular morphology; mild traction bronchiectasis; no pleural effusion or pneumothorax. - s/p bronchoscopy (3/9): BAL in lingula, 180 mL in / 90 mL out; mucous plugs present in return fluid. Labs/micro: - SARS/flu/RSV/BioFire neg, Legionella UAg neg, Bcxs neg - procalcitonin 0.05 (2/28) $g 0.09 (3/8) 2/28 SARS-CoV-2 semi-quantitative IgG (Kantaro assay) 4,447 AU/mL [ref range, < 5 AU/mL = negative to $g40 AU/mL = Strong positive "Interpretation: The Semi-Quantitative SARS-COV-2 IgG results of $g40 AU/mL confirm the presence of circulating IgG antibodies specific for SARS-CoV-2 at high levels. Corresponding serum titers range from 960 and rise to above 2880 with increasing numerical value. "] - 3/5 ANA 1:320, homogenous - 3/5 CRP 35 $g$g 150; LDH 830 - 3/9 BAL RBC 1.95K, WBC 473/68% polys, 26% macs, bacteria seen. SARS PCR neg. GS 1-9 polys, no orgs, cx usu resp flora, fungal cx neg, - AFB neg x6 - HIV neg; no known immunosuppressive predisposition to OIs like PCP or other fungi; serum CrAg/GM/Fungitell neg and sputum PCP DFA neg
CDC 'Split Type':

Write-up: 4/2020 presumed COVID-19 (not formally diagnosed, not hospitalized) 2/07/21 Moderna vaccine #1 (date per pt''s daughter) 2/21/21 onset SOB/DOE, fever 2/24/21 Seen at Urgent Care: RML crackles and infiltrate on CXR, given azithromycin and Augmentin 2/27/21 Presented to ED with progression of SOB/DOE, fatigue, diarrhea. Hypoxemic requiring low-flow NC, B/L basilar crackles noted; started on CTX/azithro (2/27-3/3) for presumed CAP 3/08/21 Required HFNC; first seen by me personally: diffuse, distinct velcro crackles, lower $g upper fields 3/12/21 Started on high-dose steroids without improvement; unable to wean from HFNC with progressively worsening hypoxemia; pt declined intubation. 03/22/21 Patient died in Palliative Care Unit Diagnosis: Interstitial lung disease of uncertain etiology, acute interstitial pneumonitis vs. undiagnosed connective tissue disease


Changed on 5/14/2021

VAERS ID: 1169796 Before After
VAERS Form:2
Age:81.0
Sex:Female
Location:New York
Vaccinated:2021-02-07
Onset:2021-02-21
Submitted:0000-00-00
Entered:2021-04-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA #039K20A / 1 UN / IM

Administered by: Public      Purchased by: ??
Symptoms: Blood culture negative, Blood lactate dehydrogenase increased, Bronchiectasis, Bronchoscopy, C-reactive protein increased, Chest X-ray abnormal, Computerised tomogram abnormal, Death, Diarrhoea, Dyspnoea, Fatigue, HIV test negative, Hypoxia, Interstitial lung disease, Lung infiltration, Neutrophil count increased, Pyrexia, Red blood cell count increased, White blood cell count increased, Nodule, Bacterial test positive, Antinuclear antibody positive, Acute interstitial pneumonitis, Endotracheal intubation, Respiratory syncytial virus test negative, Mycobacterium test negative, Legionella test, Fungal test negative, Influenza virus test negative, Procalcitonin normal, Lung opacity, SARS-CoV-2 test negative, SARS-CoV-2 antibody test

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2021-03-22
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 24     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Denied
Allergies: NKDA NKDA
Diagnostic Lab Data: - CT (3/3): moderate bilateral, predominantly dependent and peripheral/subpleural reticular and irregular groundglass and consolidative opacities, some with slightly rounded/nodular morphology; mild traction bronchiectasis; no pleural effusion or pneumothorax. - s/p bronchoscopy (3/9): BAL in lingula, 180 mL in / 90 mL out; mucous plugs present in return fluid. Labs/micro: - SARS/flu/RSV/BioFire neg, Legionella UAg neg, Bcxs neg - procalcitonin 0.05 (2/28) $g 0.09 (3/8) 2/28 SARS-CoV-2 semi-quantitative IgG (Kantaro assay) 4,447 AU/mL [ref range, < 5 AU/mL = negative to $g40 AU/mL = Strong positive "Interpretation: The Semi-Quantitative SARS-COV-2 IgG results of $g40 AU/mL confirm the presence of circulating IgG antibodies specific for SARS-CoV-2 at high levels. Corresponding serum titers range from 960 and rise to above 2880 with increasing numerical value. "] - 3/5 ANA 1:320, homogenous - 3/5 CRP 35 $g$g 150; LDH 830 - 3/9 BAL RBC 1.95K, WBC 473/68% polys, 26% macs, bacteria seen. SARS PCR neg. GS 1-9 polys, no orgs, cx usu resp flora, fungal cx neg, - AFB neg x6 - HIV neg; no known immunosuppressive predisposition to OIs like PCP or other fungi; serum CrAg/GM/Fungitell neg and sputum PCP DFA neg
CDC 'Split Type':

Write-up: 4/2020 presumed COVID-19 (not formally diagnosed, not hospitalized) 2/07/21 Moderna vaccine #1 (date per pt''s daughter) 2/21/21 onset SOB/DOE, fever 2/24/21 Seen at Urgent Care: RML crackles and infiltrate on CXR, given azithromycin and Augmentin 2/27/21 Presented to ED with progression of SOB/DOE, fatigue, diarrhea. Hypoxemic requiring low-flow NC, B/L basilar crackles noted; started on CTX/azithro (2/27-3/3) for presumed CAP 3/08/21 Required HFNC; first seen by me personally: diffuse, distinct velcro crackles, lower $g upper fields 3/12/21 Started on high-dose steroids without improvement; unable to wean from HFNC with progressively worsening hypoxemia; pt declined intubation. 03/22/21 Patient died in Palliative Care Unit Diagnosis: Interstitial lung disease of uncertain etiology, acute interstitial pneumonitis vs. undiagnosed connective tissue disease

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