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From the 9/17/2021 release of VAERS data:

This is VAERS ID 1449453



Case Details

VAERS ID: 1449453 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Unknown  
Vaccinated:2021-04-09
Onset:2021-06-01
   Days after vaccination:53
Submitted: 0000-00-00
Entered: 2021-07-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Deep vein thrombosis, Pulmonary embolism
SMQs:, Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad)

Life Threatening? No
Birth Defect? No
Died? No
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:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20212

Write-up: developed DVT with PE; developed DVT with PE; This spontaneous case was reported by a consumer and describes the occurrence of DEEP VEIN THROMBOSIS (developed DVT with PE) and PULMONARY EMBOLISM (developed DVT with PE) in a patient of an unknown age and gender who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch no. Unknown) for COVID-19 vaccination. No Medical History information was reported. On 09-Apr-2021, the patient received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) dosage was changed to 1 dosage form. On an unknown date, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. In June 2021, the patient experienced DEEP VEIN THROMBOSIS (developed DVT with PE) (seriousness criterion medically significant) and PULMONARY EMBOLISM (developed DVT with PE) (seriousness criterion medically significant). At the time of the report, DEEP VEIN THROMBOSIS (developed DVT with PE) and PULMONARY EMBOLISM (developed DVT with PE) outcome was unknown. The patient had no history of DVT or clotting issues. No concomitants medicines were reported. No treatment information was provided. Action taken with mRNA-1273 in response to the event was not applicable. Very limited information regarding these events has been provided at this time. Further information has been requested.; Sender''s Comments: Very limited information regarding these events has been provided at this time. Further information has been requested.


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