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

This is VAERS ID 1199203



Case Details

VAERS ID: 1199203 (history)  
Form: Version 2.0  
Age: 51.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:2021-03-19
Onset:2021-04-09
   Days after vaccination:21
Submitted: 0000-00-00
Entered: 2021-04-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805022 / 1 AR / IM

Administered by: Other       Purchased by: ?
Symptoms: Atelectasis, Computerised tomogram thorax abnormal, Limb mass, Pulmonary arterial hypertension, Pulmonary embolism
SMQs:, Embolic and thrombotic events, venous (narrow), Pulmonary hypertension (narrow), Cardiomyopathy (broad), Infective pneumonia (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Clindamycin lotion topical TID
Current Illness:
Preexisting Conditions: Possibly undiagnosed obstructive sleep apnea
Allergies: Benzocaine, Aspirin
Diagnostic Lab Data: CTA Chest, PE Protocol on 04/09/2021 IMPRESSION: Large pulmonary embolism in the right main pulmonary artery, right upper, middle and lower lobe pulmonary artery segmental branches and left lingular subsegmental branches. There is associated pulmonary artery hypertension with pulmonary artery measuring up to 3.6 cm. Low lung volumes. Minimal atelectasis in the left lower lobe. No consolidation.
CDC Split Type:

Write-up: Patient had a large pulmonary embolism 3 weeks after receiving the vaccine. Unclear if vaccination was the cause, but giving the timing we are reporting it. The health care proxy also noted some palpable masses on distal L extremity, unclear if related to vaccine or what these are.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1199203

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