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This is VAERS ID 1418591

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History of Changes from the VAERS Wayback Machine

First Appeared on 6/25/2021

VAERS ID: 1418591
VAERS Form:2
Age:91.0
Sex:Female
Location:Foreign
Vaccinated:2021-03-17
Onset:2021-04-01
Submitted:0000-00-00
Entered:2021-06-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 300042722 / 2 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Pulmonary thrombosis, Angiogram

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-05-12
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: CACIT VITAMINE D3 1000 mg/880 MONOPROST 50 microgrammes/ml, ; LACTULOSE; HYDROCHLOROTHIAZIDE; KARDEGIC 75 mg, ; CARDENSIEL 1,25 mg, ; IRBESARTAN; STAGID 700 mg,
Current Illness: Hypertension arterial; Type 2 diabetes mellitus
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Test Date: 20210401; Test Name: CT angiography; Test Result: Inconclusive ; Result Unstructured Data
CDC 'Split Type': FRMODERNATX, INC.MOD20212

Write-up: Double thrombose pulmonaire; This regulatory authority case was reported by a consumer and describes the occurrence of PULMONARY THROMBOSIS (Double thrombose pulmonaire) in a 91-year-old female patient who received mRNA-1273 (COVID 19 Vaccine Moderna) (batch no. 300042722) for COVID-19 vaccination. Concurrent medical conditions included Type 2 diabetes mellitus and Hypertension arterial. Concomitant products included CACIT VITAMINE D3 1000 mg/880 UI, LATANOPROST (MONOPROST 50 microgrammes/ml), LACTULOSE, HYDROCHLOROTHIAZIDE, KARDEGIC 75 mg, , CARDENSIEL 1,25 mg, comprim? pellicul?, IRBESARTAN and STAGID 700 mg, comprim? s?cable for an unknown indication. On 17-Mar-2021, the patient received second dose of mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) 1 dosage form. On 01-Apr-2021, the patient experienced PULMONARY THROMBOSIS (Double thrombose pulmonaire) (seriousness criteria death and medically significant). The patient died on 12-May-2021. The reported cause of death was Pulmonary thrombosis. It is unknown if an autopsy was performed. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On 01-Apr-2021, Angiogram: embolie pulmonaire (Inconclusive) embolie pulmonaire proximale bilat?rale avec signes de gravit?. Treatment information was not provided. On an unknown date, the patient had a COVID-19 PCR test that was negative. Very limited information regarding the event has been provided at this time. Further information is not expected. Sender''s Case Number: FR-AFSSAPS-2021065147. Most recent FOLLOW-UP information incorporated above includes: On 15-Jun-2021: Follow up was received on 15 Jun 2021. Updated the date of death, added medical history, concomitant medications, batch number, the start and end date of event.; Sender''s Comments: Very limited information regarding the event has been provided at this time. Further information is not expected.; Reported Cause(s) of Death: Pulmonary thrombosis

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