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

This is VAERS ID 1420106

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Case Details

VAERS ID: 1420106 (history)  
Form: Version 2.0  
Age: 44.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-05-01
Onset:2021-05-01
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 3002188 / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Obstructive airways disorder
SMQs:, Angioedema (broad), Asthma/bronchospasm (broad), Eosinophilic pneumonia (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: BUVENTOL
Current Illness: Asthma; Chronic obstructive pulmonary disease
Preexisting Conditions: Medical History/Concurrent Conditions: Opioid abuse
Allergies:
Diagnostic Lab Data:
CDC Split Type: SEMODERNATX, INC.MOD20212

Write-up: This regulatory authority case was reported by a physician and describes the occurrence of OBSTRUCTIVE AIRWAYS DISORDER in a 44-year-old male patient who received mRNA-1273 (COVID 19 Vaccine Moderna) (batch no. 3002188) for COVID-19 vaccination. The patient''s past medical history included Opioid abuse. Concurrent medical conditions included Asthma and Chronic obstructive pulmonary disease. Concomitant products included SALBUTAMOL SULFATE (BUVENTOL) 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. In May 2021, the patient experienced OBSTRUCTIVE AIRWAYS DISORDER (seriousness criteria death, hospitalization and life threatening). The reported cause of death was Airways obstruction. It is unknown if an autopsy was performed. For mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular), the reporter did not provide any causality assessments. No treatment information was provided. Action taken with mRNA-1273 in response to the event was not applicable. This is a case of death in a 44-year-old male subject with a history of Asthma and Chronic obstructive pulmonary disease, who died after receiving second dose of vaccine Very limited information has been provided at this time. Most recent FOLLOW-UP information incorporated above includes: On 10-Jun-2021: Translation received on 18-Jun-2021.Description to be coded was updated(Severe obstruction).; Sender''s Comments: This is a case of death in a 44-year-old male subject with a history of Asthma and Chronic obstructive pulmonary disease, who died after receiving second dose of vaccine Very limited information has been provided at this time.; Reported Cause(s) of Death: Airways obstruction


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