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This is VAERS ID 1404390

History of Changes from the VAERS Wayback Machine

First Appeared on 7/23/2021

VAERS ID: 1404390
VAERS Form:2
Age:30.0
Sex:Male
Location:Foreign
Vaccinated:2021-06-03
Onset:2021-06-04
Submitted:0000-00-00
Entered:2021-06-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 3002332 / 1 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Chills, Headache, Myalgia, Rash papular, SARS-CoV-2 test

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Clinical trial participant
Allergies:
Diagnostic Lab Data: Test Name: COVID-19 virus test; Test Result: Negative ; Result Unstructured Data: Negative
CDC 'Split Type': GBMODERNATX, INC.MOD20212

Write-up: Generalized raised red spots trunk; Headache; Chills; Muscle ache; This regulatory authority case was reported by a consumer and describes the occurrence of RASH PAPULAR (Generalized raised red spots trunk), HEADACHE (Headache), CHILLS (Chills) and MYALGIA (Muscle ache) in a 30-year-old male patient who received mRNA-1273 (Moderna CoviD-19 Vaccine) (batch no. 3002332) for COVID-19 vaccination. The patient''s past medical history included Clinical trial participant. On 03-Jun-2021, the patient received first dose of mRNA-1273 (Moderna CoviD-19 Vaccine) (Intramuscular) 1 dosage form. On 04-Jun-2021, the patient experienced RASH PAPULAR (Generalized raised red spots trunk) (seriousness criterion medically significant), HEADACHE (Headache) (seriousness criterion medically significant), CHILLS (Chills) (seriousness criterion medically significant) and MYALGIA (Muscle ache) (seriousness criterion medically significant). At the time of the report, RASH PAPULAR (Generalized raised red spots trunk), HEADACHE (Headache), CHILLS (Chills) and MYALGIA (Muscle ache) had not resolved. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On an unknown date, SARS-CoV-2 test: negative (Negative) Negative. The action taken with mRNA-1273 (Moderna CoviD-19 Vaccine) (Intramuscular) was unknown. Concomitant product use was not provided. Treatment information was 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.; 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.

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