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This is VAERS ID 1177800

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History of Changes from the VAERS Wayback Machine

First Appeared on 4/8/2021

VAERS ID: 1177800
VAERS Form:2
Age:80.0
Sex:Male
Location:Texas
Vaccinated:2021-02-25
Onset:2021-02-25
Submitted:0000-00-00
Entered:2021-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012A21A / 1 - / IM

Administered by: Private      Purchased by: ??
Symptoms: Death, Dyspnoea, Hypoxia, Interstitial lung disease, Myalgia, Pneumonia, Pyrexia, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-07
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: Fexofenadine, Dyazide, amlodipine, Vilamit, tamsulosin, dutasteride, ondansetron
Current Illness: HTN, Allergic rhinitis
Preexisting Conditions: See #11
Allergies: None known
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Rapid onset in fever and myalgia. Dyspnea and hypoxia developed over days, and eventually patient was hospitalized with bilateral pneumonia consistent with COVID-19, however patient had multiple negative tests for SARS-CoV-2, both antigen and PCR. Patient eventually diagnosed with interstitial lung disease prior to expiring on 4/7/2021.


Changed on 5/7/2021

VAERS ID: 1177800 Before After
VAERS Form:2
Age:80.0
Sex:Male
Location:Texas
Vaccinated:2021-02-25
Onset:2021-02-25
Submitted:0000-00-00
Entered:2021-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012A21A / 1 - / IM

Administered by: Private      Purchased by: ??
Symptoms: Death, Dyspnoea, Hypoxia, Interstitial lung disease, Myalgia, Pneumonia, Pyrexia, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-07
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: Fexofenadine, Dyazide, amlodipine, Vilamit, tamsulosin, dutasteride, ondansetron
Current Illness: HTN, Allergic rhinitis
Preexisting Conditions: See #11
Allergies: None known known
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Rapid onset in fever and myalgia. Dyspnea and hypoxia developed over days, and eventually patient was hospitalized with bilateral pneumonia consistent with COVID-19, however patient had multiple negative tests for SARS-CoV-2, both antigen and PCR. Patient eventually diagnosed with interstitial lung disease prior to expiring on 4/7/2021.


Changed on 5/14/2021

VAERS ID: 1177800 Before After
VAERS Form:2
Age:80.0
Sex:Male
Location:Texas
Vaccinated:2021-02-25
Onset:2021-02-25
Submitted:0000-00-00
Entered:2021-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012A21A / 1 - / IM

Administered by: Private      Purchased by: ??
Symptoms: Death, Dyspnoea, Hypoxia, Interstitial lung disease, Myalgia, Pneumonia, Pyrexia, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-07
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: Fexofenadine, Dyazide, amlodipine, Vilamit, tamsulosin, dutasteride, ondansetron
Current Illness: HTN, Allergic rhinitis
Preexisting Conditions: See #11
Allergies: None known known
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Rapid onset in fever and myalgia. Dyspnea and hypoxia developed over days, and eventually patient was hospitalized with bilateral pneumonia consistent with COVID-19, however patient had multiple negative tests for SARS-CoV-2, both antigen and PCR. Patient eventually diagnosed with interstitial lung disease prior to expiring on 4/7/2021.

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