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This is VAERS ID 1221127

History of Changes from the VAERS Wayback Machine

First Appeared on 4/23/2021

VAERS ID: 1221127
VAERS Form:2
Age:
Sex:Female
Location:Texas
Vaccinated:2021-01-22
Onset:2021-01-29
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Brain stem thrombosis

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-30
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:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No medically reported history)
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: Died of clots in brain; This spontaneous case was reported by a consumer (subsequently medically confirmed) and describes the occurrence of BRAIN STEM THROMBOSIS (Died of clots in brain) in a 76-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The patient''s past medical history included No adverse event (No medically reported history). On 22-Jan-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On 29-Jan-2021, the patient experienced BRAIN STEM THROMBOSIS (Died of clots in brain) (seriousness criteria death and medically significant). The patient died on 30-Jan-2021. The reported cause of death was Brain stem thrombosis. It is unknown if an autopsy was performed. This is a 76 year-old, who received mRNA-1273 Vaccine) and died 8 days after receiving first dose of vaccine and subsequently experienced brain stem thrombosis. No medical hx or conmeds were provided. The reported cause of death was brain stem thrombosis. Very limited information has been reported at this time. Further information is expected. This case was linked to MOD21-075103, US-MODERNATX, INC.-MOD-2021-075124 (Linked Report).; Sender''s Comments: This is a 76 year-old, who received mRNA-1273 Vaccine) and died 8 days after receiving first dose of vaccine and subsequently experienced brain stem thrombosis. No medical hx or conmeds were provided. The reported cause of death was brain stem thrombosis. Very limited information has been reported at this time. Further information is expected. MOD21-075103: US-MODERNATX, INC.-MOD-2021-075124:Patient''s brother in law case; Reported Cause(s) of Death: brain stem thrombosis


Changed on 5/7/2021

VAERS ID: 1221127 Before After
VAERS Form:2
Age:
Sex:Female
Location:Texas
Vaccinated:2021-01-22
Onset:2021-01-29
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Brain stem thrombosis

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-30
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:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No medically reported history)
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: Died of clots in brain; This spontaneous case was reported by a consumer (subsequently medically confirmed) and describes the occurrence of BRAIN STEM THROMBOSIS (Died of clots in brain) in a 76-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The patient''s past medical history included No adverse event (No medically reported history). On 22-Jan-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On 29-Jan-2021, the patient experienced BRAIN STEM THROMBOSIS (Died of clots in brain) (seriousness criteria death and medically significant). The patient died on 30-Jan-2021. The reported cause of death was Brain stem thrombosis. It is unknown if an autopsy was performed. This is a 76 year-old, who received mRNA-1273 Vaccine) and died 8 days after receiving first dose of vaccine and subsequently experienced brain stem thrombosis. No medical hx or conmeds were provided. The reported cause of death was brain stem thrombosis. Very limited information has been reported at this time. Further information is expected. This case was linked to MOD21-075103, US-MODERNATX, INC.-MOD-2021-075124 (Linked Report).; Sender''s Comments: This is a 76 year-old, who received mRNA-1273 Vaccine) and died 8 days after receiving first dose of vaccine and subsequently experienced brain stem thrombosis. No medical hx or conmeds were provided. The reported cause of death was brain stem thrombosis. Very limited information has been reported at this time. Further information is expected. MOD21-075103: US-MODERNATX, INC.-MOD-2021-075124:Patient''s brother in law case; Reported Cause(s) of Death: brain stem thrombosis


Changed on 5/14/2021

VAERS ID: 1221127 Before After
VAERS Form:2
Age:
Sex:Female
Location:Texas
Vaccinated:2021-01-22
Onset:2021-01-29
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Brain stem thrombosis

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-30
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:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No medically reported history)
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: Died of clots in brain; This spontaneous case was reported by a consumer (subsequently medically confirmed) and describes the occurrence of BRAIN STEM THROMBOSIS (Died of clots in brain) in a 76-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The patient''s past medical history included No adverse event (No medically reported history). On 22-Jan-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On 29-Jan-2021, the patient experienced BRAIN STEM THROMBOSIS (Died of clots in brain) (seriousness criteria death and medically significant). The patient died on 30-Jan-2021. The reported cause of death was Brain stem thrombosis. It is unknown if an autopsy was performed. This is a 76 year-old, who received mRNA-1273 Vaccine) and died 8 days after receiving first dose of vaccine and subsequently experienced brain stem thrombosis. No medical hx or conmeds were provided. The reported cause of death was brain stem thrombosis. Very limited information has been reported at this time. Further information is expected. This case was linked to MOD21-075103, US-MODERNATX, INC.-MOD-2021-075124 (Linked Report).; Sender''s Comments: This is a 76 year-old, who received mRNA-1273 Vaccine) and died 8 days after receiving first dose of vaccine and subsequently experienced brain stem thrombosis. No medical hx or conmeds were provided. The reported cause of death was brain stem thrombosis. Very limited information has been reported at this time. Further information is expected. MOD21-075103: US-MODERNATX, INC.-MOD-2021-075124:Patient''s brother in law case; Reported Cause(s) of Death: brain stem thrombosis

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