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From the 9/10/2021 release of VAERS data:

This is VAERS ID 1381668



Case Details

VAERS ID: 1381668 (history)  
Form: Version 2.0  
Age: 16.0  
Sex: Female  
Location: California  
Vaccinated:2021-05-03
Onset:2021-06-04
   Days after vaccination:32
Submitted: 0000-00-00
Entered: 2021-06-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0167 / 2 AR / IM

Administered by: Other       Purchased by: ?
Symptoms: Anaemia, Arthralgia, Blood albumin decreased, Blood culture negative, Blood fibrinogen increased, C-reactive protein increased, Complement factor normal, Culture throat negative, Culture urine negative, Fibrin D dimer increased, Haemoglobin, Joint swelling, Mycoplasma test negative, Peripheral swelling, Pyrexia, Rash, Respiratory viral panel, Sterile pyuria, Streptococcus test, Urticaria, White blood cell count increased
SMQs:, Cardiac failure (broad), Anaphylactic reaction (broad), Angioedema (narrow), Haematopoietic erythropenia (broad), Haemorrhage laboratory terms (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (narrow), Arthritis (broad), Tubulointerstitial diseases (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow)

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? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: none
Allergies: none
Diagnostic Lab Data: CRP elevated to 74, elevated D dimer, elevated fibrinogen, anemia from Hgb 14-$g10, albumin 2.7, sterile pyuria 25 WBC, normal complements, ASO titer, negative blood, urine, and throat cultures, negative respiratory panel for 15 pathogens, including mycoplasma (6/6-$g6/8/21 for all testing)
CDC Split Type:

Write-up: Fever, urticarial rash to face, neck trunk, and extremities, arthralgias and swelling to hands, feet, ankles, left knee and left elbow occurring 4 weeks after vaccine lasting for 4 days in hospital after 2 days at home. still resolving slowly


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1381668


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