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This is VAERS ID 1301881

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First Appeared on 7/2/2021

VAERS ID: 1301881
VAERS Form:2
Age:85.0
Sex:Female
Location:Foreign
Vaccinated:2021-01-16
Onset:2021-02-18
Submitted:0000-00-00
Entered:2021-05-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Pulmonary embolism

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-18
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Angiopathy; Diabetes mellitus insulin-dependent; Hypertension
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': HUMODERNATX, INC.MOD20211

Write-up: Lung embolism; This regulatory authority case was reported by an other health care professional and describes the occurrence of PULMONARY EMBOLISM (Lung embolism) in an 85-year-old female patient who received mRNA-1273 (COVID 19 Vaccine Moderna) for COVID-19 vaccination. The patient''s past medical history included Hypertension, Diabetes mellitus insulin-dependent and Angiopathy. On 16-Jan-2021, the patient received first dose of mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) .5 ml. On 13-Feb-2021, received second dose of mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) dosage was changed to .5 ml. On 18-Feb-2021, the patient experienced PULMONARY EMBOLISM (Lung embolism) (seriousness criterion death). The patient died on 18-Feb-2021. The reported cause of death was Lung embolism. It is unknown if an autopsy was performed. For mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular), the reporter did not provide any causality assessments. No concomitant medications were provided Treatment for the events were not provided Company comment: This is a case of death in a 85-year-old female subject with a medical history of HTN, DM, and angiopathy, who died 5 days after receiving the second dose of vaccine. Very limited information has been provided at this time. No follow up is possible.; Sender''s Comments: This is a case of death in a 85-year-old female subject with a medical history of HTN, DM, and angiopathy, who died 5 days after receiving the second dose of vaccine. Very limited information has been provided at this time. No follow up is possible.; Reported Cause(s) of Death: Lung embolism

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