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

This is VAERS ID 1391042



Case Details

VAERS ID: 1391042 (history)  
Form: Version 2.0  
Age: 13.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-06-03
Onset:2021-06-04
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-06-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 LA / -

Administered by: Work       Purchased by: ?
Symptoms: SARS-CoV-2 antibody test, Vaccination site pain, Vaccination site rash, Vaccination site swelling
SMQs:, Hypersensitivity (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Appendectomy (Appendectomy in Feb2019, otherwise healthy boy)
Allergies:
Diagnostic Lab Data: Test Date: 20201005; Test Name: Nasal Swab; Result Unstructured Data: Test Result:Negative; Test Date: 20210307; Test Name: Nasal Swab; Result Unstructured Data: Test Result:Negative
CDC Split Type: USPFIZER INC2021656745

Write-up: left arm deltoid injection site with red circular rash with well defined border; There was general swelling (puffy/boggy) of upper arm centered around the injection site that extended under the rash 4 inches in diameter with diffuse/tapered border.; The injection site was very tender to palpation w/ pain raising or using arm.; This is a spontaneous report from contactable consumer (patient). A 13-year-old male patient received BNT162b2 (PFIZER BIONTECH COVID-19 mRNA VACCINE, Solution for injection, Lot number- UNKNOWN) via an unspecified route of administration in left arm on 03Jun2021 at 10:30 as 2nd dose, single dose for COVID-19 immunization. Medical history included appendectomy in Feb2019, otherwise healthy boy. Patient previously took Amoxicillin and experienced full body rash. Concomitant medications were not reported. The patient did not receive any other vaccines within 4 weeks prior to the COVID vaccine. Patient did not receive any other medications the patient received within 2 weeks of vaccination. On 05Oct2020, patient had been tested for COVID-19 via Nasal Swab and resulted negative. Prior to vaccination, patient was not diagnosed with COVID-19. Historical vaccine included BNT162b2 (PFIZER BIONTECH COVID-19 mRNA VACCINE, Solution for injection, Lot number- unknown) via an unspecified route of administration in left arm on 13May2021 at 09:15 AM as 1st dose, single dose for COVID-19 immunization. It was reported that, patient experienced on left arm deltoid injection site with red circular rash with well defined border that was not raised and about 2 inches in diameter. Does not itch. There was general swelling (puffy/boggy) of upper arm centered around the injection site that extended under the rash 4 inches in diameter with diffuse/tapered border. The injection site was very tender to palpation w/ pain raising or using arm. This was only a day following the 2nd injection (On 04Jun2021 at 14:00). No treatment was received for the adverse events. Since the vaccination, the patient had been tested for COVID-19 via Nasal Swab. On 07Mar2021, patient tested COVID-19 and resulted negative. The device date was 05Jun2021. The outcome of the events was recovering. Information about batch/ lot number has been requested.


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