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

This is VAERS ID 1403355

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Case Details

VAERS ID: 1403355 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Male  
Location: California  
   Days after vaccination:29
Submitted: 0000-00-00
Entered: 2021-06-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805029 / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Blood test, Cardiomegaly, Chest discomfort, Computerised tomogram, Drain placement, Duodenitis, Echocardiogram abnormal, Fatigue, Flank pain, Myalgia, Nasopharyngitis, Pericardial drainage, Pericardial effusion, Pericarditis
SMQs:, Rhabdomyolysis/myopathy (broad), Cardiac failure (broad), Anaphylactic reaction (broad), Systemic lupus erythematosus (broad), Retroperitoneal fibrosis (broad), Gastrointestinal nonspecific inflammation (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (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? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Cholesterol medicine
Current Illness: None
Preexisting Conditions: Gout in 2008 was just hospitalized for pericarditis May 28 , 2021 for 4 days. No history of heart problems before this.
Allergies: None
Diagnostic Lab Data: Echocardiogram, cat scan, blood work. Still waiting most of these results except echocardiogram.
CDC Split Type:

Write-up: Began feeling like trying to catch a cold. Tired, tight chest, muscles sore. Symptoms continued for a couple weeks then a deep pain in side started. Could not stand the side pain and went to ER. Scan showed enlarged cardiac silhouette. Further tests showed fluid completely surrounding heart with inflammation in duodenum. Was taking into surgery to have fluid from heart sac drained then a drain put in.

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