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This is VAERS ID 1181240

History of Changes from the VAERS Wayback Machine

First Appeared on 7/2/2021

VAERS ID: 1181240
VAERS Form:2
Age:
Sex:Female
Location:Foreign
Vaccinated:0000-00-00
Onset:2021-03-15
Submitted:0000-00-00
Entered:2021-04-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 300042723 / 1 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Haemoglobin, Pancytopenia, Platelet count, Subdural haematoma, White blood cell count

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-16
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: CALCIGRAN FORTE; NORMORIX; SIMVASTATIN; BEHEPAN [CYANOCOBALAMIN]; SELO-ZOK; SOMAC; AMLODIPINE; ZYLORIC; PROLIA; ALBYL-E
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Aortic stenosis; Atrial fibrillation; Hypertension
Allergies:
Diagnostic Lab Data: Test Date: 20210315; Test Name: Hemoglobin; Result Unstructured Data: 7.0; Test Date: 20210315; Test Name: Thrombocyte count; Result Unstructured Data: <5 Not measurable; Test Date: 20210315; Test Name: Leukocyte count; Result Unstructured Data: 1.1
CDC 'Split Type': NOMODERNATX, INC.MOD20210

Write-up: Pancytopenia; Subdural hematoma; This regulatory authority case was reported by a physician (subsequently medically confirmed) and describes the occurrence of PANCYTOPENIA (Pancytopenia) and SUBDURAL HAEMATOMA (Subdural hematoma) in an 89-year-old female patient who received mRNA-1273 (COVID 19 Vaccine Moderna) (batch no. 300042723) for COVID-19 vaccination. Concurrent medical conditions included Atrial fibrillation, Hypertension and Aortic stenosis. Concomitant products included CALCIUM CARBONATE, COLECALCIFEROL (CALCIGRAN FORTE) from an unknown date to 16-Mar-2021, AMILORIDE HYDROCHLORIDE, HYDROCHLOROTHIAZIDE (NORMORIX) from an unknown date to 16-Mar-2021, SIMVASTATIN from an unknown date to 16-Mar-2021, CYANOCOBALAMIN (BEHEPAN [CYANOCOBALAMIN]) from an unknown date to 16-Mar-2021, METOPROLOL SUCCINATE (SELO-ZOK) from an unknown date to 16-Mar-2021, PANTOPRAZOLE SODIUM SESQUIHYDRATE (SOMAC) from an unknown date to 16-Mar-2021, AMLODIPINE, ALLOPURINOL (ZYLORIC) from an unknown date to 16-Mar-2021, DENOSUMAB (PROLIA) from an unknown date to 16-Mar-2021 and ACETYLSALICYLIC ACID, MAGNESIUM OXIDE (ALBYL-E) from an unknown date to 16-Mar-2021 for an unknown indication. On an unknown date, the patient received first dose of mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) 1 dosage form. On 15-Mar-2021, the patient experienced SUBDURAL HAEMATOMA (Subdural hematoma) (seriousness criterion death). On an unknown date, the patient experienced PANCYTOPENIA (Pancytopenia) (seriousness criterion death). The patient died on 16-Mar-2021. The cause of death was not reported. It is unknown if an autopsy was performed. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On 15-Mar-2021, Haemoglobin: 7.0 7.0. On 15-Mar-2021, Platelet count: <5 not measurable <5 Not measurable. On 15-Mar-2021, White blood cell count: 1.1 1.1. The action taken with mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) was unknown. For mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular), the reporter considered PANCYTOPENIA (Pancytopenia) and SUBDURAL HAEMATOMA (Subdural hematoma) to be possibly related. This is a case of sudden death in a 89-year-old female patient with a history of Atrial fibrillation, Hypertension and Aortic stenosis, who died after receiving first dose of vaccine (date unknown). Very limited information has been provided at this time. Reporter did not allow further contact; Sender''s Comments: This is a case of sudden death in a 89-year-old female patient with a history of Atrial fibrillation, Hypertension and Aortic stenosis, who died after receiving first dose of vaccine (date unknown). Very limited information has been provided at this time.; Reported Cause(s) of Death: Unknown cause of death

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