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From the 11/19/2021 release of VAERS data:

This is VAERS ID 1380073

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Case Details

VAERS ID: 1380073 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-05-06
Onset:2021-05-07
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-06-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19 pneumonia, SARS-CoV-2 test, Suspected COVID-19
SMQs:, Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-09
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: PERINDOPRIL; SIRDALUD; FURON [FUROSEMIDE]; VITAMIN D3; SKUDEXA; THEOSPIREX [THEOPHYLLINE]; FEMIFLO; KALDYUM; PANTOPRAZOLE
Current Illness: Hypertension
Preexisting Conditions: Medical History/Concurrent Conditions: COVID-19 pneumonia; Hip dislocation; Kidney failure chronic; Multiple sclerosis; Suspected COVID-19
Allergies:
Diagnostic Lab Data: Test Date: 20210509; Test Name: COVID-19 antigen test; Test Result: Negative ; Result Unstructured Data: Negative; Test Date: 20210509; Test Name: COVID-19 PCR test; Test Result: Negative ; Result Unstructured Data: Negative
CDC Split Type: HUMODERNATX, INC.MOD20211

Write-up: Covid-19 v?rus; COVID-19 pneumonia; This case was received via an unknown source (no reference has been entered for a health authority or license partner) on 31-May-2021 and was forwarded to Moderna on 31-May-2021. This regulatory authority case was reported by a physician and describes the occurrence of SUSPECTED COVID-19 (Covid-19 v?rus) and COVID-19 PNEUMONIA (COVID-19 pneumonia) in a 72-year-old male patient who received mRNA-1273 (COVID 19 Vaccine Moderna) for COVID-19 vaccination. The patient''s past medical history included Multiple sclerosis, Kidney failure chronic, COVID-19 pneumonia, Suspected COVID-19 and Hip dislocation. Concurrent medical conditions included Hypertension. Concomitant products included PERINDOPRIL, TIZANIDINE HYDROCHLORIDE (SIRDALUD), FUROSEMIDE (FURON [FUROSEMIDE]), COLECALCIFEROL (VITAMIN D3), DEXKETOPROFEN TROMETAMOL, TRAMADOL HYDROCHLORIDE (SKUDEXA), THEOPHYLLINE (THEOSPIREX [THEOPHYLLINE]), FLUCONAZOLE (FEMIFLO), POTASSIUM CHLORIDE (KALDYUM) and PANTOPRAZOLE for an unknown indication. On 06-May-2021, the patient received second dose of mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) dosage was changed to .5 milliliter. On an unknown date, the patient received first dose of mRNA-1273 (COVID 19 Vaccine Moderna) (unknown route) 1 dosage form. On 07-May-2021, the patient experienced SUSPECTED COVID-19 (Covid-19 v?rus) (seriousness criterion death) and COVID-19 PNEUMONIA (COVID-19 pneumonia) (seriousness criteria death and medically significant). The patient died on 09-May-2021. The reported cause of death was COVID-19 pneumonia and Suspected COVID-19. An autopsy was not performed. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On 09-May-2021, SARS-CoV-2 test: negative (Negative) Negative and negative (Negative) Negative. For mRNA-1273 (COVID 19 Vaccine Moderna) (Unknown), the reporter considered SUSPECTED COVID-19 (Covid-19 v?rus) and COVID-19 PNEUMONIA (COVID-19 pneumonia) to be unlikely related. Treatment for the events were not provided. Company Comment: According to the SmPC of COVID-19 VACCINE MODERNA, immunity usually develops 14 days after the second dose of the vaccine. The patient started having Covid-19 symptoms 1 day after the second dose, therefore immunity may have not developed yet. Covid pneumonia was also confirmed. Based on the above, the causal relationship is unlikely between the adverse events and the suspected drug. The case is serious because the outcome was fatal. Further information is not expected.; Sender''s Comments: According to the SmPC of COVID-19 VACCINE MODERNA, immunity usually develops 14 days after the second dose of the vaccine. The patient started having Covid-19 symptoms 1 day after the second dose, therefore immunity may have not developed yet. Covid pneumonia was also confirmed. Based on the above, the causal relationship is unlikely between the adverse events and the suspected drug. The case is serious because the outcome was fatal. Further information is not expected.; Reported Cause(s) of Death: COVID-19 Pneumonia; Suspected COVID-19


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