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

This is VAERS ID 1221058



Case Details

VAERS ID: 1221058 (history)  
Form: Version 2.0  
Age: 37.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-03-11
Onset:2021-03-22
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN MVP-COVID-19 18 / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Anaemia, Angiogram pulmonary abnormal, Antineutrophil cytoplasmic antibody negative, Antinuclear antibody, Asthenia, Bilevel positive airway pressure, Biopsy bone marrow normal, Blood fibrinogen increased, Blood glucose increased, Blood immunoglobulin G increased, Blood smear test abnormal, Bronchoscopy normal, Chest pain, Echocardiogram abnormal, Ehrlichia test, Ejection fraction decreased, Fatigue, Histone antibody negative, Intensive care, Interleukin-2 receptor assay, Leukocytosis, Magnetic resonance imaging abnormal, Magnetic resonance imaging heart, Myocarditis, Neutrophil percentage increased, Platelet count increased, Pleural effusion, Pleuritic pain, Polychromasia, Pulmonary oedema, Pyrexia, Respiratory distress, Serum ferritin increased, Shock, Upper respiratory tract infection, White blood cell count increased
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (narrow), Haematopoietic erythropenia (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Hypovolaemic shock conditions (narrow), Toxic-septic shock conditions (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypoglycaemic and neurogenic shock conditions (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (narrow), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (narrow), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Infective pneumonia (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 25 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: amoxicillin 400 mg/5mL (take 10 mL by mouth twice a day) ibuprofen 800 mg (every 8 hours as needed) insulin glargine (40 units at bedtime daily) insulin lispro 100 unit/mL (injection 12 units subcutaneously 3 time a day)
Current Illness: One month prior to vaccination pt was admitted to the hospital for altered mental status, new onset type 1 diabetes, dka, and pancreatitis. At this time pt was also found to have symptoms of shock, AKI, and hyperlipidemia.
Preexisting Conditions: diabetes (unable to determine type)
Allergies: no known allergies
Diagnostic Lab Data: Ferritin: (4/13) 11,844; (3/31) $g 40,000 MRI cardiac: (3/26) LVEF 45% supported myocarditis Echo: (3/22) EF 40-45%; (3/27) 60-65%; (4/9) 50-55% Anaplasma phagocytophilum abs: (4/3) negative proteinase 3-Ab: (4/5) negative Anti histone antibodies: (4/3) negative Anti- scleroderma: (4/5) negative IL-2 RAlpha: (4/1) 6150 CTA: (3/28) pleural effusions, negative for PE WBC: (4/15) 33.43 PLT: (4/15) 782 Neutrophil %: (4/15) 92% Polychromasia: (4/15) 2+ Fibrinogen: (4/13) 738
CDC Split Type:

Write-up: Pt admitted to the ICU on 3/22/21 w/ pleuritic chest pain and shock requiring vasopressors. At time of admission pt had been taking antibiotics for an upper respiratory infection for 3 days. Echo Lv 40-45% upon admission. Pt was determined to have myopericarditis. On 3/24/21 pt was transferred to the cardiac intermediate unit. Endocrine consulted while in the cardiac intermediate unit to control his elevated blood sugars- endocrine team unable to determine if blood sugar is type 1 or type 2. on 3/27/21 pt went into respiratory distress required bipap & high flow nasal cannula and had a fever. Pulmonary consulted at this time- determined to be related to pulmonary edema and not a PE positive for pleural effusion. ID has been negative up to this point. 4/9/21 pt transferred to internal medicine service for work up for fever of unknown origin and continued management. Rheumatology consulted for leukocytosis, anemia, and elevated IgG. Ruled out connective tissue disease, stills disease, and vasculitis. Histoplasma was borderline positive pt has had recent bat exposure. Bone marrow biopsy done on 4/13/2021, ruled out HLH. Bronch done 4/15 to assess for TB, histoplasma, negative results so far. As of 4/15 no recommendations from ID and patient continues to look weaker/fatigued and spikes fever.


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