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

This is VAERS ID 1376604

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Case Details

VAERS ID: 1376604 (history)  
Form: Version 2.0  
Age: 23.0  
Sex: Male  
Location: New Jersey  
Vaccinated:2021-06-05
Onset:2021-06-05
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1820096 / 1 RA / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Cyanosis, Dizziness, Head injury, Hypertension, Loss of consciousness, Nervous system disorder, Seizure, Syncope, Tremor, Unresponsive to stimuli, Urinary incontinence, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Convulsions (narrow), Parkinson-like events (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypertension (narrow), Cardiomyopathy (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
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:
CDC Split Type:

Write-up: Systemic: Dizziness / Lightheadness-Severe, Systemic: Fainting / Unresponsive-Severe, Systemic: Hypertension-Medium, Systemic: Neurological Disorder (diagnosed by MD)-Medium, Systemic: Seizure-Medium, Systemic: Shakiness-Medium, Systemic: Vomiting-Medium, Additional Details: after receiving the J&J vaccine on 6/5/21 about 1.5 minutes after administration the patient hit his head against the wall and was unconscious. the patient started to mildly seize and lips started turning cyanotic and the patient urinated himself. The whole episode lasting about 45 seconds. When the patient came to he informed me that was epileptic. I kept the patient in the supine position until the paramedics arrived on the scene shortly after.


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