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

This is VAERS ID 1376866

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Case Details

VAERS ID: 1376866 (history)  
Form: Version 2.0  
Age: 20.0  
Sex: Female  
Location: Alaska  
Vaccinated:2021-06-04
Onset:2021-06-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 203A21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dizziness, Immediate post-injection reaction, Loss of consciousness, Malaise, Seizure
SMQs:, Torsade de pointes/QT prolongation (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), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (narrow), Hypersensitivity (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: None
Preexisting Conditions: None
Allergies: Amoxicillin (hives)
Diagnostic Lab Data:
CDC Split Type:

Write-up: Immediately after the vaccine was administered, the patient stated that she felt sick and light headed. I instructed her to remove her mask, place her head between her legs and take some deep breaths. Before she had completely bent over she lost consciousness and began seizing. She remained in the chair for the duration of the event and until the paramedics took her out of the pharmacy. I made sure she did not injure herself or fall out of the chair and when the event was over I called ED. I continued to monitor the patient until she was taken by paramedics.


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