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

This is VAERS ID 1271213

Case Details

VAERS ID: 1271213 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Pennsylvania  
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Private       Purchased by: ?
Symptoms: Acidosis, Acute hepatic failure, Acute kidney injury, Alanine aminotransferase increased, Aspartate aminotransferase increased, Blood gases abnormal, Blood glucose increased, Blood lactic acid increased, Cardiac arrest, Chronic kidney disease, Computerised tomogram, Death, Diabetic ketoacidosis, Endotracheal intubation, Glucose tolerance test, Hypotension, Insulin tolerance test, Intensive care, Metabolic function test, Nausea, Resuscitation, Sedative therapy, Unresponsive to stimuli, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Liver related investigations, signs and symptoms (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Anaphylactic reaction (broad), Acute pancreatitis (broad), Angioedema (broad), Lactic acidosis (narrow), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-29
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: acetaminophen (TYLENOL) 325 mg tablet ascorbic acid, vitamin C, (VITAMIN C) 1,000 mg tablet ascorbic acid-multivit,mins 18 1,000 mg tablet aspirin 81 mg tablet BD ULTRA-FINE SHORT PEN NEEDLE 31 gauge x 5/16" needle bimatoprost (LUMIGAN) 0.0
Current Illness: none
Preexisting Conditions: Nervous Intermittent claudication (CMS/HCC) Circulatory Coronary artery disease involving native coronary artery of native heart without angina pectoris Hypertension, essential Peripheral arterial disease (CMS/HCC) NSTEMI (non-ST elevated myocardial infarction) (CMS/HCC) Acute on chronic systolic heart failure (CMS/HCC) Cardiac arrest (CMS/HCC) Digestive Diverticular disease of colon Acute liver failure Genitourinary Stage 3b chronic kidney disease Type 2 diabetes mellitus with diabetic nephropathy (CMS/HCC) Hypertensive chronic kidney disease CKD (chronic kidney disease) stage 4, GFR 15-29 ml/min (CMS/HCC) Endocrine/Metabolic Hyperlipidemia Other Presence of combination internal cardiac defibrillator (ICD) and pacemaker
Allergies: CiprofloxacinSwelling DoxycyclineSwelling RosuvastatinMyalgia / Muscle Pain SimvastatinMyalgia / Muscle Pain Statins-hmg-coa Reductase InhibitorsMyalgia / Muscle Pain
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient is a 80 y.o. male with significant PMHx of CAD, HTN, HLD, CKD who is admitted to ICU as a transfer from hospital for acute liver failure and cardiac arrest. Pt presented to hospital on 04/28 w/ complaints of nausea and vomiting. He stated that he had recently gotten his COVID vaccine. Pt was found to be in acute liver failure in the ED w/ AST and ALT $g 1000. Lactate $g 15.0. BMP showed AKI on CKD and BG $g500. Pt did have cardiac arrest while undergoing CT Scan and ROSC was achieved after CPR x 20 mins. Pt was hence transferred to the ICU for higher level management and admitted for cardiac arrest and acute liver failure. Upon arrival, Pt was intubated and sedated. He was non-responsive to verbal and physical stimuli. Pt was acidotic. ABG: 6.99 / 28 / 165 / 7. 1 amp of HCO3 was given upon arrival. Pt was started on insulin gtt for DKA and was started on Levophed for low BP. Pt underwent cardiac arrest shortly after arrival to the ICU. CPR was performed for $g 20 mins without ROSC. Family arrived at bedside and decision was made to stop CPR at 0205 on 04/29/2021.

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