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This is VAERS ID 1173209

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History of Changes from the VAERS Wayback Machine

First Appeared on 7/2/2021

VAERS ID: 1173209
VAERS Form:2
Age:92.0
Sex:Female
Location:Foreign
Vaccinated:2021-03-05
Onset:2021-03-05
Submitted:0000-00-00
Entered:2021-04-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA G 26761A / 1 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Pericardial haemorrhage

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-05
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? No
Previous Vaccinations:
Other Medications: CHINOTAL; TALLITON; INDAPAMIDE; CAVINTON FORTE; ELIQUIS; TENAXUM; FURON [FUROSEMIDE SODIUM]; POTASSIUM CHLORIDE; BETASERC
Current Illness: Atrial fibrillation; Dizziness; Generalized arteriosclerosis; Hypertension; Myocardial ischaemia
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': HUMODERNATX, INC.MOD20210

Write-up: Haemopericardium; This regulatory authority case was reported by a physician (subsequently medically confirmed) and describes the occurrence of PERICARDIAL HAEMORRHAGE (Haemopericardium) in a 92-year-old female patient who received mRNA-1273 (COVID 19 Vaccine Moderna) (batch no. G 26761A) for COVID-19 vaccination. Concurrent medical conditions included Generalized arteriosclerosis, Myocardial ischaemia, Atrial fibrillation, Hypertension and Dizziness. Concomitant products included APIXABAN (ELIQUIS) for Atrial fibrillation, VINPOCETINE (CAVINTON FORTE) and BETAHISTINE HYDROCHLORIDE (BETASERC) for Dizziness, PENTOXIFYLLINE (CHINOTAL) for Generalised arteriosclerosis, INDAPAMIDE and RILMENIDINE PHOSPHATE (TENAXUM) for Hypertension, CARVEDILOL (TALLITON) and POTASSIUM CHLORIDE for Myocardial ischaemia, FUROSEMIDE SODIUM (FURON [FUROSEMIDE SODIUM]) for an unknown indication. On 05-Mar-2021, the patient received first dose of mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) 1 dosage form. On 05-Mar-2021, after starting mRNA-1273 (COVID 19 Vaccine Moderna), the patient experienced PERICARDIAL HAEMORRHAGE (Haemopericardium) (seriousness criterion death). The patient died on 05-Mar-2021. The reported cause of death was Haemopericardium. An autopsy was performed, but no results were provided. For mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular), the reporter considered PERICARDIAL HAEMORRHAGE (Haemopericardium) to be unlikely related. Based on the current available information and temporal association between the use of the product and the start date of the event, a causal relationship cannot be excluded. Reporter did not allow further contact; Sender''s Comments: Based on the current available information and temporal association between the use of the product and the start date of the event, a causal relationship cannot be excluded.; Reported Cause(s) of Death: Haemopericardium

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