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From the 6/11/2021 release of VAERS data:

This is VAERS ID 1264911



Case Details

VAERS ID: 1264911 (history)  
Form: Version 2.0  
Age: 19.0  
Sex: Female  
Location: Kansas  
Vaccinated:2021-04-12
Onset:2021-04-21
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-04-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 203A21A / 1 LA / SYR

Administered by: Work       Purchased by: ?
Symptoms: Lip swelling, Pharyngeal swelling, Urticaria
SMQs:, Anaphylactic reaction (narrow), Angioedema (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Prevnar August 2001
Other Medications: Escitalopram
Current Illness: None
Preexisting Conditions: Depression and Anxiety
Allergies: Penicillin, Prevnar vaccine
Diagnostic Lab Data: None
CDC Split Type:

Write-up: She had a severe allergic reaction. Swollen lips, throat, hives.


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