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From the 7/23/2021 release of VAERS data:

This is VAERS ID 1327577



Case Details

VAERS ID: 1327577 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-04-21
Onset:2021-05-04
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-05-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 008C21A / 1 RA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 008C21A / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Condition aggravated, Erythema, Feeding disorder, Stomatitis, Swelling
SMQs:, Severe cutaneous adverse reactions (broad), Anaphylactic reaction (broad), Angioedema (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Metoprolol, Synthroid
Current Illness:
Preexisting Conditions: HTN, Thyroid disease
Allergies: none
Diagnostic Lab Data: none available
CDC Split Type:

Write-up: Pt started on 5/4/2021 with generalized erythema and swelling. This progressed for which he visited his PCP who recommended benadryl. Condition worsened until irritation affected the inside of his mouth, causing him difficulty eating. He wento to ER at Hospital on 5/13/2021 and was admitted for IV treatment (steoids??). He was treated by an Internist and ID Specialist (unknown names) who explained that this was secondary to the Moderna vaccine. He was discharged home on 5/16/2021 to continue on PO steoids. He denies exposure to any other potential allergen after his vaccine was administered (no new medications, or allergy-prone foods). Currently, patient is slowly improving.


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