National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

This is VAERS ID 1419673

Government Disclaimer on use of this data

History of Changes from the VAERS Wayback Machine

First Appeared on 6/25/2021

VAERS ID: 1419673
VAERS Form:2
Age:33.0
Sex:Male
Location:Foreign
Vaccinated:2021-05-01
Onset:2021-05-01
Submitted:0000-00-00
Entered:2021-06-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 3001942 / 1 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-05-01
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: LAMOTRIGINE; MOVICOL [MACROGOL 3350;POTASSIUM CHLORIDE;SODIUM BICARBONATE;SODIUM CHLORIDE]; THERALEN; KEPPRA [LEVETIRACETAM]; CIRCADIN; MIRTAZAPINE; LORATADINE
Current Illness: Epilepsy
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': SEMODERNATX, INC.MOD20212

Write-up: Death; This regulatory authority case was reported by a consumer and describes the occurrence of DEATH (Death) in a 33-year-old male patient who received mRNA-1273 (COVID 19 Vaccine Moderna) (batch no. 3001942) for COVID-19 vaccination. Concurrent medical conditions included Epilepsy. Concomitant products included LAMOTRIGINE, MACROGOL 3350, POTASSIUM CHLORIDE, SODIUM BICARBONATE, SODIUM CHLORIDE (MOVICOL [MACROGOL 3350;POTASSIUM CHLORIDE;SODIUM BICARBONATE;SODIUM CHLORIDE]), ALIMEMAZINE TARTRATE (THERALEN), LEVETIRACETAM (KEPPRA [LEVETIRACETAM]), MELATONIN (CIRCADIN), MIRTAZAPINE and LORATADINE for an unknown indication. In May 2021, the patient received second dose of mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) dosage was changed to 1 dosage form. On an unknown date, the patient received first dose of mRNA-1273 (COVID 19 Vaccine Moderna) (unknown route) 1 dosage form. Death occurred on May 2021 The patient died in May 2021. The cause of death was not reported. It is unknown if an autopsy was performed. Treatment information was not provided. Company Comment: This is a case of death not otherwise specified in a 33-year-old male patient with a medical history of epilepsy on antiepileptic therapy, that occurred on an unknown number of days after receiving second dose of vaccine (Lot number 3001942). Very limited information regarding the clinical details pertaining to death was provided at this time. No further information is expected. Most recent FOLLOW-UP information incorporated above includes: On 10-Jun-2021: Translated document contains no significant information.; Sender''s Comments: This is a case of death not otherwise specified in a 33-year-old male patient with a medical history of epilepsy on antiepileptic therapy, that occurred on an unknown number of days after receiving second dose of vaccine (Lot number 3001942). Very limited information regarding the clinical details pertaining to death was provided at this time. No further information is expected.; Reported Cause(s) of Death: Unknown cause of death

New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1419673&WAYBACKHISTORY=ON


Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166