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From the 11/26/2021 release of VAERS data:

This is VAERS ID 1269149

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Case Details

VAERS ID: 1269149 (history)  
Form: Version 2.0  
Age: 31.0  
Sex: Male  
Location: New York  
Submitted: 0000-00-00
Entered: 2021-04-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: Myalgia, Pericarditis
SMQs:, Rhabdomyolysis/myopathy (broad), Systemic lupus erythematosus (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Cigarette smoker (vapourizer.)
Preexisting Conditions: Comments: The patient had No known prior medical history and No known allergies.
Diagnostic Lab Data:
CDC Split Type: USJNJFOC20210448217

Write-up: PERICARDITIS; MYALGIA; This spontaneous report received from a physician concerned a 31 year old male. The patient''s height, and weight were not reported. The patient''s concurrent conditions included cigarette smoker, and other pre-existing medical conditions included the patient had no known allergies and no known medical history. The patient received covid-19 vaccine ad26.cov2.s (suspension for injection, route of admin not reported, batch number: Unknown) with unspecified dose 1 total, administered on 06-APR-2021 for prophylactic vaccination. The batch number was not reported and has been requested. No concomitant medications were reported. On 06-APR-2021 the patient had experienced fever, myalgia. On 20-APR-2021 the patient diagnosed with pericarditis, chest discomfort and was hospitalized, patient had reported these symptoms to health care professional. The action taken with covid-19 vaccine ad26.cov2.s was not applicable. The patient had not recovered from pericarditis, fever, chest discomfort, and myalgia. This report was serious (Hospitalization Caused / Prolonged).; Sender''s Comments: V0: 20210448217-COVID-19 VACCINE AD26.COV2.S-Pericarditis. This event(s) is considered unassessable. The event(s) has a compatible/suggestive temporal relationship, is unlabeled, and has unknown scientific plausibility. There is no information on any other factors potentially associated with the event(s).

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