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This is VAERS ID 1443000

History of Changes from the VAERS Wayback Machine

First Appeared on 7/9/2021

VAERS ID: 1443000
VAERS Form:2
Age:18.0
Sex:Male
Location:Foreign
Vaccinated:2021-04-21
Onset:2021-06-04
Submitted:0000-00-00
Entered:2021-07-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Myocarditis

Life Threatening? No
Birth Defect? No
Died? No
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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': DEPEI202100104153

Write-up: Myokarditis; This regulatory authority case was reported by a physician and describes the occurrence of MYOCARDITIS (Myokarditis) in an 18-year-old male patient who received mRNA-1273 (COVID 19 Vaccine Moderna) (batch no. 3002334) for COVID-19 vaccination. No Medical History information was reported. On 21-Apr-2021, the patient received first dose of mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) 1 dosage form. On 01-Jun-2021, received second dose of mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) dosage was changed to 1 dosage form. On 04-Jun-2021, the patient experienced MYOCARDITIS (Myokarditis) (seriousness criteria hospitalization and medically significant). At the time of the report, MYOCARDITIS (Myokarditis) had not resolved. For mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular), the reporter did not provide any causality assessments. Concomitant medication were not provided by the reporter. Treatment information was not provided by the reporter. Based on the 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. Action taken with mRNA-1273 to the events was not applicable; Sender''s Comments: Based on the 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.

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