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

This is VAERS ID 1434214

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Case Details

VAERS ID: 1434214 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-05-07
Onset:2021-05-01
Submitted: 0000-00-00
Entered: 2021-06-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 3001531 / 1 RA / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Aortic dissection, Dyspnoea, Dyspnoea exertional, Fibrin D dimer, Malaise, Oxygen saturation, Pulmonary embolism, Respiratory rate
SMQs:, Anaphylactic reaction (broad), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-03
   Days after onset: 33
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: AMLODIPIN ACCORD; LOSARTAN MEDIC VALLEY; DURAPHAT
Current Illness: Aortic dissection (Small possibility of Aortic dissection (small OBS)); Hypertension
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Test Date: 20210603; Test Name: Fibrin D dimer; Test Result: Inconclusive ; Result Unstructured Data: Unknown; Test Date: 20210603; Test Name: Oxygen saturation; Test Result: Inconclusive 95 %; Result Unstructured Data: Oxygen saturation-95%; Test Date: 20210603; Test Name: Respiratory rate; Test Result: Inconclusive ; Result Unstructured Data: Unknown
CDC Split Type: DKMODERNATX, INC.MOD20212

Write-up: Acute unwell; Possible lung embolism with fatal ourcome; Hospitalised due to progressive dyspnoea through 4 weeks; Dyspnoea exertional; aortic dissection.; This regulatory authority case was reported by a physician and describes the occurrence of PULMONARY EMBOLISM (Possible lung embolism with fatal ourcome), AORTIC DISSECTION (aortic dissection.), DYSPNOEA (Hospitalised due to progressive dyspnoea through 4 weeks), DYSPNOEA EXERTIONAL (Dyspnoea exertional) and MALAISE (Acute unwell) in a 79-year-old male patient who received mRNA-1273 (COVID 19 Vaccine Moderna) (batch no. 3001531) for COVID-19 vaccination. Concurrent medical conditions included Hypertension and Aortic dissection (Small possibility of Aortic dissection (small OBS)). Concomitant products included SODIUM FLUORIDE (DURAPHAT) from 20-May-2020 to an unknown date for Caries dental, AMLODIPINE BESILATE (AMLODIPIN ACCORD) from 08-Mar-2016 to an unknown date and LOSARTAN POTASSIUM (LOSARTAN MEDIC VALLEY) from 20-Feb-2018 to an unknown date for Hypertension. On 07-May-2021, the patient received first dose of mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) 1 dosage form. In May 2021, the patient experienced PULMONARY EMBOLISM (Possible lung embolism with fatal ourcome) (seriousness criteria death, hospitalization prolonged and medically significant), AORTIC DISSECTION (aortic dissection.) (seriousness criteria death and medically significant), DYSPNOEA (Hospitalised due to progressive dyspnoea through 4 weeks) (seriousness criteria death and hospitalization prolonged) and DYSPNOEA EXERTIONAL (Dyspnoea exertional) (seriousness criteria death and hospitalization prolonged). On 03-Jun-2021, the patient experienced MALAISE (Acute unwell) (seriousness criteria death and hospitalization prolonged). The patient died on 03-Jun-2021. The reported cause of death was Lung embolism and Aortic dissection. An autopsy was not performed. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On 03-Jun-2021, Fibrin D dimer: unknown (Inconclusive) Unknown. On 03-Jun-2021, Oxygen saturation: 95 percent (Inconclusive) Oxygen saturation-95%. On 03-Jun-2021, Respiratory rate: unknown (Inconclusive) Unknown. For mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular), the reporter did not provide any causality assessments. Patients treatment product details was not provided by reporter. This fatal case concerns a 79-year-old male hospitalized with serious unexpected events of pulmonary embolism, aortic dissection, dyspnea, dyspnea exertional and malaise. Event latency x days after mRNA-1273. Based on current available information and temporal association between the use of the product and the start date of the event, a causal relationship cannot be excluded.; Sender''s Comments: This fatal case concerns a 79-year-old male hospitalized with serious unexpected events of pulmonary embolism, aortic dissection, dyspnea, dyspnea exertional and malaise. Event latency x days after mRNA-1273. Based on current available information and temporal association between the use of the product and the start date of the event, a causal relationship cannot be excluded.; Reported Cause(s) of Death: Lung embolism; Aortic dissection


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