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

This is VAERS ID 1435294

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Case Details

VAERS ID: 1435294 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-05-08
Onset:2021-05-20
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-06-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 3001655 / UNK - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Dyspnoea exertional, Gastrointestinal haemorrhage, Renal failure, Sepsis, Skin ulcer
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Gastrointestinal haemorrhage (narrow), Pulmonary hypertension (broad), Ischaemic colitis (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-04
   Days after onset: 15
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Atrial fibrillation; Decompensation cardiac; Implantable defibrillator user; Prostatic carcinoma
Allergies:
Diagnostic Lab Data:
CDC Split Type: ITMODERNATX, INC.MOD20212

Write-up: This regulatory authority case was reported by a physician and describes the occurrence of GASTROINTESTINAL HAEMORRHAGE, SEPSIS, RENAL FAILURE, DYSPNOEA EXERTIONAL and SKIN ULCER in a 73-year-old male patient who received mRNA-1273 (COVID 19 Vaccine Moderna) (batch no. 3001655) for COVID-19 vaccination. The patient''s past medical history included Implantable defibrillator user, Atrial fibrillation, Decompensation cardiac and Prostatic carcinoma. On 08-May-2021, the patient received dose of mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) 1 dosage form. On 20-May-2021, the patient experienced GASTROINTESTINAL HAEMORRHAGE (seriousness criteria death and medically significant), SEPSIS (seriousness criteria death and medically significant), RENAL FAILURE (seriousness criteria death and medically significant), DYSPNOEA EXERTIONAL (seriousness criterion death) and SKIN ULCER (seriousness criterion death). The patient died on 04-Jun-2021. The reported cause of death was gastrointestinal haemorrhage, sepsis, renal failure, dyspnoea exertional and skin ulcer. It is unknown if an autopsy was performed. For mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular), the reporter did not provide any causality assessments. Concomitant medication use was not provided. No Treatment information was provided. Action taken with mRNA-1273 in response to the event was not applicable Company Comment: 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.; Reported Cause(s) of Death: gastrointestinal haemorrhage, sepsis, renal failure, dyspnoea exertional and skin ulcer


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