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From the 6/4/2021 release of VAERS data:

This is VAERS ID 1233697



Case Details

VAERS ID: 1233697 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Male  
Location: Colorado  
Vaccinated:2021-04-10
Onset:2021-04-11
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 201A21A / 1 LA / IM
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 201A21A / 1 LA / IM

Administered by: Military       Purchased by: ?
Symptoms: Ageusia, Anosmia, Asthma, Blood albumin decreased, Blood creatine phosphokinase increased, Blood creatinine increased, Blood glucose increased, Blood sodium decreased, COVID-19, Chest X-ray normal, Chest discomfort, Chest pain, Chills, Coagulation test normal, Condition aggravated, Diabetes mellitus, Diarrhoea, Differential white blood cell count normal, Dyspnoea, Echocardiogram abnormal, Electrocardiogram normal, Fibrin D dimer normal, Full blood count normal, Glycosylated haemoglobin increased, Headache, Hypoglycaemia, Hypoxia, Influenza A virus test negative, Influenza B virus test, Lung infiltration, Metabolic function test, Myalgia, Nausea, Protein total decreased, Pyrexia, SARS-CoV-2 test positive, Tachycardia, Tachypnoea, Troponin T increased, Troponin increased, Vomiting
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Asthma/bronchospasm (narrow), Hyperglycaemia/new onset diabetes mellitus (narrow), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Taste and smell disorders (narrow), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Pseudomembranous colitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hyponatraemia/SIADH (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Noninfectious diarrhoea (narrow), Tumour lysis syndrome (broad), Respiratory failure (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (narrow), Infective pneumonia (broad), Dehydration (broad), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Cozaar, Norvasc, HCTZ, Lipitor, NovoLIN R, Lantis
Current Illness:
Preexisting Conditions: ASTHMA, CHRONIC KIDNEY DISEASE, DIABETES, HYPERTENSION, TOBACCO ABUSE DX OF COVID-19 15 APRIL 21.
Allergies: NKDA
Diagnostic Lab Data: 4/15/21 IN ED Port CXR - NEGATIVE, on discussion with Radiologist, subtle focal infiltrate consistent with COVID infiltrates, per ED note. CBC unremarkable; CMP elevated glucose, Elevated Troponin, Creatine Kinase Elevated, D-Dimer within normal range, EKG unremarkable, Influenza A & B negative, COVID 19 Positive, Coag panel within normal limits 4/16/21 CXR - Normal, Glucose - at 1720 374, at 2,225 338 , Troponin T - Elevated21.43 (Ref Range 19), Hemaglobin A1C 13.3 CMP Creatinine 1.36, Sodium low at 131, Glucose 258, D-Dimer within normal limits, CBC unremarkable, 4/17/21 Glucose 47 @ 1720, CMP W/GFR Glucose 43 @ 0500, CBC/W/Diff unremarkable. 4/18/21 Glucose @0215 55 CBC W/Diff unremarkable, CMP@ 0827 Albumin low, Creatinine high, glucose 131, protein low, sodium low, 4/19/21 Echocardiogram: There is an echodensity in the right atrium which measures 1 cm x 1 cm best appreciated in apical four-chamber imaging. This may represent a prominent crista terminalis ridge but recommended further imaging such as cardiac MRI (given acute COVID 19 infection) forfurther evalaution. CBC w/ Diff unremarkable, CMP creatinine high, glucose high, proien low, sodium low.
CDC Split Type:

Write-up: Patient received Jassen vaccine 4/10/21. 4/11/21 began with symptoms of fever, headache, chills, nausea, vomiting, and diarrhea, loss of taste and smell. 4/15/21 he presented to ED with symptoms of fever, chest pain and pressure, shortness o breath, myalgias, headache, tachypnea, tachycardia, hypoxia. Was given IV Decadron, DuoNeb and albuerol in ED. Inprovment seen, but patient continued with tachypnea and difficulty breathing. He was admitted to ED with a diagnosis of COVID 19 , asthma exacerbation and elevated Troponin at 31.52 (Ref Range 19) . During admission, glucose levels were labile, requiring adjustment to routine insulin regimen and Glucovance for hypoglycemia. An Echocardiogram was ordered due to elevated Troponin levels on admission. Echocardiogram 4/19/21 showed a density in the right atrium. Cardiology recommended a cardiac MRI. Patient was transfered to Hospital 4/19/21 for elevated care and evaluation, with diagnosis of


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