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

This is VAERS ID 1330936



Case Details

VAERS ID: 1330936 (history)  
Form: Version 2.0  
Age: 13.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-05-19
Onset:2021-05-19
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-05-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0183 / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cyanosis, Disorientation, Fatigue, Nausea, Pulse abnormal, Seizure, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Dementia (broad), Convulsions (narrow), 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), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (narrow), Hypoglycaemia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Pulse 83 Respirations 18 SPO2 100% BP 90/60 Exam was abnormal, patient felt fatigue and nauseous VSS Heart and lung sounds normal
CDC Split Type:

Write-up: Patient had convulsive seizure, became unresponsive and was cyanotic, sternal rub, patient opened eyes. Heart rate was thready. Patient felt nauseous. Patient was disoriented for 1min and quickly regained orientation. Patient was given water, patient laid on the floor. Discharged to ER Past Medical Hx Hx of seizure at age 4


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