National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

From the 10/8/2021 release of VAERS data:

This is VAERS ID 1231868

Case Details

VAERS ID: 1231868 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Foreign  
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Unknown       Purchased by: ?
Symptoms: Septic shock
SMQs:, Toxic-septic shock conditions (narrow), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Atrial fibrillation; Axillary abscess; Chronic kidney disease stage 3; Diabetes mellitus; Dysphagia; Hypertensive cardiomyopathy; Metabolic syndrome; Peripheral arterial disease; Polyneuropathy; Spinal cord injury; Stroke
Preexisting Conditions:
Diagnostic Lab Data:

Write-up: Septic shock; This case was received via an unknown source (no reference has been entered for a health authority or license partner) on 13-Apr-2021 and was forwarded to Moderna on 13-Apr-2021. This regulatory authority case was reported by a pharmacist (subsequently medically confirmed) and describes the occurrence of SEPTIC SHOCK (Septic shock) in a 69-year-old male patient who received mRNA-1273 (COVID-19 Vaccine Moderna) (batch no. 3000496) for COVID-19 vaccination. Concurrent medical conditions included Spinal cord injury, Polyneuropathy, Diabetes mellitus, Dysphagia, Stroke, Hypertensive cardiomyopathy, Atrial fibrillation, Peripheral arterial disease, Metabolic syndrome, Chronic kidney disease stage 3 and Axillary abscess since February 2021. On 09-Mar-2021, the patient received dose of mRNA-1273 (COVID-19 Vaccine Moderna) (Intramuscular) at an unspecified dose. On 14-Mar-2021, the patient experienced SEPTIC SHOCK (Septic shock) (seriousness criterion death). The patient died on 14-Mar-2021. The reported cause of death was Septic shock. An autopsy was not performed. For mRNA-1273 (COVID-19 Vaccine Moderna) (Intramuscular), the reporter considered SEPTIC SHOCK (Septic shock) to be unlikely related. Action taken with mRNA-1273 in response to the event was not applicable. No treatment information was provided. Reporter did not allow further contact; Sender''s Comments: Very limited information regarding the event has been provided at this time and is insufficient for causality assessment.; Reported Cause(s) of Death: Septic shock

New Search

Link To This Search Result:

Government Disclaimer on use of this data

Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166