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

This is VAERS ID 1380472

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Case Details

VAERS ID: 1380472 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-02-18
Onset:2021-02-19
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-06-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 30004272L / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Activated partial thromboplastin time, Acute kidney injury, Alanine aminotransferase, Aspartate aminotransferase, Autopsy, Base excess, Basophil percentage, Blood bicarbonate, Blood bilirubin, Blood creatinine, Blood culture, Blood glucose, Blood osmolarity, Blood potassium, Blood sodium, Blood thyroid stimulating hormone, Blood urea, Blood uric acid, Body temperature, C-reactive protein, Dyspnoea, Electrocardiogram, Embolism, Eosinophil percentage, Escherichia sepsis, Fibrin D dimer, Gallbladder enlargement, General physical health deterioration, Haematocrit, Haemoglobin, Hyperuricaemia, International normalised ratio, Left ventricular hypertrophy, Leukopenia, Liver injury, Lymphocyte percentage, Mean cell haemoglobin, Mean cell haemoglobin concentration, Mean cell volume, Mean platelet volume, Monocyte percentage, Neutrophil percentage, Oxygen saturation, PCO2, PO2, Physical examination, Platelet count, Platelet distribution width, Platelet-large cell ratio, Procalcitonin, Prothrombin time, Pyrexia, Red blood cell count, Red cell distribution width, Renal cyst, Respiratory failure, SARS-CoV-2 test, Troponin T, White blood cell count, pH body fluid
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Anaphylactic reaction (broad), Haematopoietic leukopenia (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Acute central respiratory depression (narrow), Gallbladder related disorders (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Hypersensitivity (broad), Tumour lysis syndrome (narrow), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Dehydration (broad), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-22
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Atherosclerosis generalised (High-grade); Chronic cystitis; Chronic obstructive pulmonary disease; Type 2 diabetes mellitus
Preexisting Conditions: Medical History/Concurrent Conditions: Aortic valve calcification; Left ventricular hypertrophy; Lung neoplasm; Mediastinum neoplasm; Prostatic hyperplasia; Tobacco abuse
Allergies:
Diagnostic Lab Data: Test Date: 20210224; Test Name: Autopsy; Test Result: Inconclusive ; Result Unstructured Data: Initial diagnosis: a lardaceous tumor of the hilus and lower lobe of the right lung, 7x70 cm in size and surrounded by satellite nodules of various sizes. Metastases to the lymph nodes of the right hilum of the lung and to the lymph nodes of the tracheal bifurcation. The entire right lung, except for the tumor, is gray, poppy and disintegrates when touched. Left lung with signs of hyperemia and emphysema. High-grade generalized atherosclerosis. Left ventricular hypertrophy. Aortic valve calcification. Significant enlargement of the gallbladder. Small cysts of the kidney cortex (0.5 cm in diameter). Chronic cystitis. Prostatic hypertrophy.; Test Date: 20210220; Test Name: Base excess; Test Result: Inconclusive ; Result Unstructured Data: -7.9 mmol/l; Test Date: 20210220; Test Name: Basophil percentage; Test Result: Inconclusive ; Result Unstructured Data: 0; Test Date: 20210220; Test Name: Blood bicarbonate; Test Result: Inconclusive ; Result Unstructured Data: 16; Test Date: 20210220; Test Name: Bilirubin total; Test Result: Inconclusive ; Result Unstructured Data: 0.6; Test Date: 20210220; Test Name: Blood creatinine; Test Result: Inconclusive ; Result Unstructured Data: 2.4; Test Date: 20210221; Test Name: Blood culture; Test Result: Inconclusive ; Result Unstructured Data: Investigation was terminated on 24-Feb-2021. E. coli was grown in anaerobic culture Amoxicillin/clavulanic acid R (MIC $g=32.0) Cefuroxime I (MIC4.0) Piperacillin / Tazobactam S (MIC <=4.0) Ceftazidime S (MIC <= 0.12) Cefotaxime S (MIC <= 0.25) Cefepim S (MIC <= 0.12) Imipenem S (MIC <= 0.25) Meropenem S (MIC <= 0.25) Gentamycyna S (MIC <= 1.0) Amikacin S (MIC <= 2.0) Ciprofloxacin S (MIC <= 0.25) Trimethoprim / Sulfamethoxazole S (MIC <= 20.0); Test Date: 20210221; Test Name: Blood culture; Test Result: Inconclusive ; Result Unstructured Data: Investigation was terminated on 24-Feb-2021. E. coli was grown in aerobic culture Amoxicillin/clavulanic acid R (MIC $g=32.0) Cefuroxime I (MIC4.0) Piperacillin / Tazobactam S (MIC <=4.0) Ceftazidime S (MIC <= 0.12) Cefotaxime S (MIC <= 0.25) Cefepim S (MIC <= 0.12) Imipenem S (MIC <= 0.25) Meropenem S (MIC <= 0.25) Gentamycyna S (MIC <= 1.0) Amikacin S (MIC <= 2.0) Ciprofloxacin S (MIC <= 0.25) Trimethoprim / Sulfamethoxazole S (MIC <= 20.0); Test Date: 20210220; Test Name: Blood glucose; Test Result: Inconclusive ; Result Unstructured Data: 120; Test Date: 20210221; Test Name: Glucose; Test Result: Inconclusive ; Result Unstructured Data: 7 am: 107mg% 5 pm: 82 mg%; Comments: glycemic profile; Test Date: 20210220; Test Name: Osmolality; Test Result: Inconclusive ; Result Unstructured Data: 269; Test Date: 20210220; Test Name: Blood potassium; Test Result: Inconclusive ; Result Unstructured Data: 4.2; Test Date: 20210220; Test Name: Blood sodium; Test Result: Inconclusive ; Result Unstructured Data: 137; Test Date: 20210220; Test Name: TSH; Test Result: Inconclusive ; Result Unstructured Data: 1.57; Comments: CRPL2; Test Date: 20210220; Test Name: Blood urea; Test Result: Inconclusive ; Result Unstructured Data: 91.6; Test Date: 20210220; Test Name: Blood uric acid; Test Result: Inconclusive ; Result Unstructured Data: 8.88; Test Date: 20210219; Test Name: Body temperature; Test Result: Inconclusive ; Result Unstructured Data: up to 39 Celsius degrees; Test Date: 20210220; Test Name: C-reactive protein; Test Result: Inconclusive ; Result Unstructured Data: 439; Comments: CRPL2; Test Date: 20210220; Test Name: Electrocardiogram; Test Result: Inconclusive ; Result Unstructured Data: sinus rhythm accompanied by tachycardia, single ventricular beats; Test Date: 20210220; Test Name: Eosinophil percentage; Test Result: Inconclusive ; Result Unstructured Data: 0; Test Date: 20210220; Test Name: Fibrin D dimer; Test Result: Inconclusive ; Result Unstructured Data: 1731; Test Date: 20210220; Test Name: Hematocrit; Test Result: Inconclusive ; Result Unstructured Data: 35.9; Test Date: 20210220; Test Name: Haemoglobin; Test Result: Inconclusive ; Result Unstructured Data: 12.1; Test Date: 20210220; Test Name: INR; Test Result: Inconclusive ; Result Unstructured Data: 1.4; Test Date: 20210220; Test Name: Lymphocyte percentage; Test Result: Inconclusive ; Result Unstructured Data: 19.2; Test Date: 20210220; Test Name: MCH; Test Result: Inconclusive ; Result Unstructured Data: 31.7; Test Date: 20210220; Test Name: MCHC; Test Result: Inconclusive ; Result Unstructured Data: 33.7; Test Date: 20210220; Test Name: MCV; Test Result: Inconclusive ; Result Unstructured Data: 94,m5; Test Date: 20210220; Test Name: Mean platelet volume; Test Result: Inconclusive ; Result Unstructured Data: 10.8; Test Date: 20210220; Test Name: Monocyte percentage; Test Result: Inconclusive ; Result Unstructured Data: 12; Test Date: 20210220; Test Name: Neutrophil percentage; Test Result: Inconclusive ; Result Unstructured Data: 68.8; Test Date: 20210220; Test Name: Oxygen saturation; Test Result: Inconclusive ; Result Unstructured Data: 88; Test Date: 20210220; Test Name: Partial pressure CO2; Test Result: Inconclusive ; Result Unstructured Data: 28.4; Test Date: 20210220; Test Name: pH; Test Result: Inconclusive ; Result Unstructured Data: 7.370; Test Date: 20210220; Test Name: Physical examination; Test Result: Inconclusive ; Result Unstructured Data: Acute alveolar respiratory murmur over the lung fields, rales in the interscapular region on both sides, more to the right.; Test Date: 20210220; Test Name: Platelet count; Test Result: Inconclusive ; Result Unstructured Data: 225; Test Date: 20210220; Test Name: Platelet distribution width; Test Result: Inconclusive ; Result Unstructured Data: 12.7; Test Date: 20210220; Test Name: Platelet-large cell ratio; Test Result: Inconclusive ; Result Unstructured Data: 32.1 %; Test Date: 20210220; Test Name: Partial pressure O2; Test Result: Inconclusive ; Result Unstructured Data: 58.3; Test Date: 20210220; Test Name: Procalcitonin; Test Result: Inconclusive ; Result Unstructured Data: 0.2 %; Test Date: 20210220; Test Name: Prothrombin time; Test Result: Inconclusive ; Result Unstructured Data: 62 %; Test Date: 20210220; Test Name: RBC count; Test Result: Inconclusive ; Result Unstructured Data: 3.82; Test Date: 20210220; Test Name: Red cell distribution width; Test Result: Inconclusive ; Result Unstructured Data: RDW-SD 47.4 fl RDW-CV 13.6 %; Test Date: 20210220; Test Name: COVID-19 PCR test; Test Result: Negative ; Result Unstructured Data: negative; Test Date: 20210220; Test Name: Troponin T; Test Result: Inconclusive ; Result Unstructured Data: 14.17; Test Date: 20210220; Test Name: WBC; Test Result: Inconclusive ; Result Unstructured Data: 2.92; Test Date: 20210220; Test Name: APTT; Test Result: Inconclusive ; Result Unstructured Data: 40; Test Date: 20210220; Test Name: Alanine aminotransferase; Test Result: Inconclusive ; Result Unstructured Data: 62.9; Test Date: 20210220; Test Name: Aspartate aminotransferase; Test Result: Inconclusive ; Result Unstructured Data: 62.6
CDC Split Type: PLMODERNATX, INC.MOD20211

Write-up: Escherishia coli sepsis; Suspicion of embolism; Small kidney cysts; Liver damage; Respiratory failure; Gallbladder enlargement; Left ventricular of heart hypertrophy; Hyperuricemia; Leukopenia; Deterioration of general condition; Dyspnoea; Acute renal failure; Fever; This regulatory authority case was reported by a physician and describes the occurrence of ESCHERICHIA SEPSIS (Escherishia coli sepsis), EMBOLISM (Suspicion of embolism), RENAL CYST (Small kidney cysts), LIVER INJURY (Liver damage), RESPIRATORY FAILURE (Respiratory failure), GALLBLADDER ENLARGEMENT (Gallbladder enlargement), LEFT VENTRICULAR HYPERTROPHY (Left ventricular of heart hypertrophy), HYPERURICAEMIA (Hyperuricemia), LEUKOPENIA (Leukopenia), GENERAL PHYSICAL HEALTH DETERIORATION (Deterioration of general condition), DYSPNOEA (Dyspnoea), ACUTE KIDNEY INJURY (Acute renal failure) and PYREXIA (Fever) in a 72-year-old male patient who received mRNA-1273 (COVID 19 Vaccine Moderna) (batch no. 30004272L) for COVID-19 vaccination. The patient''s past medical history included Tobacco abuse, Lung neoplasm, Aortic valve calcification, Aortic valve calcification, Prostatic hyperplasia, Left ventricular hypertrophy and Mediastinum neoplasm. Concurrent medical conditions included Chronic cystitis, Type 2 diabetes mellitus, Chronic obstructive pulmonary disease and Atherosclerosis generalised (High-grade). On 18-Feb-2021, the patient received first dose of mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) 1 dosage form. On 19-Feb-2021, the patient experienced ESCHERICHIA SEPSIS (Escherishia coli sepsis) (seriousness criterion death), EMBOLISM (Suspicion of embolism) (seriousness criterion death), RENAL CYST (Small kidney cysts) (seriousness criterion death), LIVER INJURY (Liver damage) (seriousness criterion death), RESPIRATORY FAILURE (Respiratory failure) (seriousness criterion death), GALLBLADDER ENLARGEMENT (Gallbladder enlargement) (seriousness criterion death), LEFT VENTRICULAR HYPERTROPHY (Left ventricular of heart hypertrophy) (seriousness criterion death), HYPERURICAEMIA (Hyperuricemia) (seriousness criterion death), LEUKOPENIA (Leukopenia) (seriousness criterion death), GENERAL PHYSICAL HEALTH DETERIORATION (Deterioration of general condition) (seriousness criterion death), DYSPNOEA (Dyspnoea) (seriousness criterion death), ACUTE KIDNEY INJURY (Acute renal failure) (seriousness criteria death and medically significant) and PYREXIA (Fever) (seriousness criterion death). The patient died on 22-Feb-2021. The cause of death was not reported. An autopsy was performed, but no results were provided. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On 19-Feb-2021, Body temperature: upto 39 (Inconclusive) up to 39 Celsius degrees. On 20-Feb-2021, Activated partial thromboplastin time: 40 (Inconclusive) 40. On 20-Feb-2021, Alanine aminotransferase: 62.9 (Inconclusive) 62.9. On 20-Feb-2021, Aspartate aminotransferase: 62.6 (Inconclusive) 62.6. On 20-Feb-2021, Base excess: -7.9 (Inconclusive) -7.9 mmol/l. On 20-Feb-2021, Basophil percentage: 0 (Inconclusive) 0. On 20-Feb-2021, Blood bicarbonate: 16 (Inconclusive) 16. On 20-Feb-2021, Blood bilirubin: 0.6 (Inconclusive) 0.6. On 20-Feb-2021, Blood creatinine: 2.4 (Inconclusive) 2.4. On 20-Feb-2021, Blood glucose: 120 (Inconclusive) 120. On 20-Feb-2021, Blood osmolarity: 269 (Inconclusive) 269. On 20-Feb-2021, Blood potassium: 4.2 (Inconclusive) 4.2. On 20-Feb-2021, Blood sodium: 137 (Inconclusive) 137. On 20-Feb-2021, Blood thyroid stimulating hormone: 1.57 (Inconclusive) 1.57. On 20-Feb-2021, Blood urea: 91.6 (Inconclusive) 91.6. On 20-Feb-2021, Blood uric acid: 8.88 (Inconclusive) 8.88. On 20-Feb-2021, C-reactive protein: 439 (Inconclusive) 439. On 20-Feb-2021, Electrocardiogram: unknown (Inconclusive) sinus rhythm accompanied by tachycardia, single ventricular beats. On 20-Feb-2021, Eosinophil percentage: 0 (Inconclusive) 0. On 20-Feb-2021, Fibrin D dimer: 1731 (Inconclusive) 1731. On 20-Feb-2021, Haematocrit: 35.9 (Inconclusive) 35.9. On 20-Feb-2021, Haemoglobin: 12.1 (Inconclusive) 12.1. On 20-Feb-2021, International normalised ratio: 1.4 (Inconclusive) 1.4. On 20-Feb-2021, Lymphocyte percentage: 19.2 (Inconclusive) 19.2. On 20-Feb-2021, Mean cell haemoglobin: 31.7 (Inconclusive) 31.7. On 20-Feb-2021, Mean cell haemoglobin concentration: 33.7 (Inconclusive) 33.7. On 20-Feb-2021, Mean cell volume: 94 (Inconclusive) 94,m5. On 20-Feb-2021, Mean platelet volume: 10.8 (Inconclusive) 10.8. On 20-Feb-2021, Monocyte percentage: 12 (Inconclusive) 12. On 20-Feb-2021, Neutrophil percentage: 68.8 (Inconclusive) 68.8. On 20-Feb-2021, Oxygen saturation: 88 (Inconclusive) 88. On 20-Feb-2021, PCO2: 28.4 (Inconclusive) 28.4. On 20-Feb-2021, PO2: 58.3 (Inconclusive) 58.3. On 20-Feb-2021, Physical examination: abnormal (Inconclusive) Acute alveolar respiratory murmur over the lung fields, rales in the interscapular region on both sides, more to the right.. On 20-Feb-2021, Platelet count: 225 (Inconclusive) 225. On 20-Feb-2021, Platelet distribution width: 12.7 (Inconclusive) 12.7. On 20-Feb-2021, Platelet-large cell ratio: 32.1 (Inconclusive) 32.1 %. On 20-Feb-2021, Procalcitonin: 0.2% (Inconclusive) 0.2 %. On 20-Feb-2021, Prothrombin time: 62% (Inconclusive) 62 %. On 20-Feb-2021, Red blood cell count: 3.82 (Inconclusive) 3.82. On 20-Feb-2021, Red cell distribution width: 47.4 (Inconclusive) RDW-SD 47.4 fl RDW-CV 13.6 %. On 20-Feb-2021, SARS-CoV-2 test: negative (Negative) negative. On 20-Feb-2021, Troponin T: 14.17 (Inconclusive) 14.17. On 20-Feb-2021, White blood cell count: 2.92 (Inconclusive) 2.92. On 20-Feb-2021, pH body fluid: 7.370 (Inconclusive) 7.370. On 21-Feb-2021, Blood culture: unknown (Inconclusive) Investigation was terminated on 24-Feb-2021. E. coli was grown in anaerobic culture Amoxicillin/clavulanic acid R (MIC $g=32.0) Cefuroxime I (MIC4.0) Piperacillin / Tazobactam S (MIC <=4.0) Ceftazidime S (MIC <= 0.12) Cefotaxime S (MIC <= 0.25) Cefepim S (MIC <= 0.12) Imipenem S (MIC <= 0.25) Meropenem S (MIC <= 0.25) Gentamycyna S (MIC <= 1.0) Amikacin S (MIC <= 2.0) Ciprofloxacin S (MIC <= 0.25) Trimethoprim / Sulfamethoxazole S (MIC <= 20.0) and unknown (Inconclusive) Investigation was terminated on 24-Feb-2021. E. coli was grown in aerobic culture Amoxicillin/clavulanic acid R (MIC $g=32.0) Cefuroxime I (MIC4.0) Piperacillin / Tazobactam S (MIC <=4.0) Ceftazidime S (MIC <= 0.12) Cefotaxime S (MIC <= 0.25) Cefepim S (MIC <= 0.12) Imipenem S (MIC <= 0.25) Meropenem S (MIC <= 0.25) Gentamycyna S (MIC <= 1.0) Amikacin S (MIC <= 2.0) Ciprofloxacin S (MIC <= 0.25) Trimethoprim / Sulfamethoxazole S (MIC <= 20.0). On 21-Feb-2021, Blood glucose: 107 (Inconclusive) 7 am: 107mg% 5 pm: 82 mg%. On 24-Feb-2021, Autopsy: abnormal (Inconclusive) Initial diagnosis: a lardaceous tumor of the hilus and lower lobe of the right lung, 7x70 cm in size and surrounded by satellite nodules of various sizes. Metastases to the lymph nodes of the right hilum of the lung and to the lymph nodes of the tracheal bifurcation. The entire right lung, except for the tumor, is gray, poppy and disintegrates when touched. Left lung with signs of hyperemia and emphysema. High-grade generalized atherosclerosis. Left ventricular hypertrophy. Aortic valve calcification. Significant enlargement of the gallbladder. Small cysts of the kidney cortex (0.5 cm in diameter). Chronic cystitis. Prostatic hypertrophy.. For mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular), the reporter considered DYSPNOEA (Dyspnoea), ACUTE KIDNEY INJURY (Acute renal failure) and PYREXIA (Fever) to be probably related and ESCHERICHIA SEPSIS (Escherishia coli sepsis), EMBOLISM (Suspicion of embolism), RENAL CYST (Small kidney cysts), LIVER INJURY (Liver damage), RESPIRATORY FAILURE (Respiratory failure), GALLBLADDER ENLARGEMENT (Gallbladder enlargement), LEFT VENTRICULAR HYPERTROPHY (Left ventricular of heart hypertrophy), HYPERURICAEMIA (Hyperuricemia), LEUKOPENIA (Leukopenia) and GENERAL PHYSICAL HEALTH DETERIORATION (Deterioration of general condition) to be possibly related. Additional medical history details included a tumor of the mediastinum and hilum of the right lung - in an ambulatory chest CT scan with contrast (09-Feb-2021), pathological infiltrative-nodal mass, also described peripherally from the tumor in the upper lobe at the apex of the segment 6 GGO density of atelectatic-inflammatory nature with accompanying fibrosis. For this reason, the patient was consulted by an oncologist and then referred to a thoracic surgeon - where after consultation, the date of bronchoscopy was scheduled and laboratory tests were ordered Concomitant product details were not provided. Treatment information not provided. Based on the current available information and temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded. Most recent FOLLOW-UP information incorporated above includes: On 26-May-2021: Translation Document received on 26-MAY-2021.; Sender''s Comments: Based on the current available information and temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded.; Reported Cause(s) of Death: unknown cause of death


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