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

This is VAERS ID 1454380

Case Details

VAERS ID: 1454380 (history)  
Form: Version 2.0  
Age: 19.0  
Sex: Male  
Location: Connecticut  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1821281 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Cough, Hypoaesthesia, Pallor, Visual impairment
SMQs:, Anaphylactic reaction (broad), Peripheral neuropathy (broad), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Glaucoma (broad), Optic nerve disorders (broad), Lens disorders (broad), Retinal disorders (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), Sexual dysfunction (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: none
Preexisting Conditions: none
Allergies: Minocycline
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received dose of vaccine. About 2 minutes later he started coughing. A minute later he started to hunch over in his chair. I went over to make sure if he fainted that he would not fall. He described numbing and tingling in both arms and face. He was having difficulty seeing complaining of seeing white. We took his Bp it was 116/70 and pulse of 63. Ge appeared pale and white. We called for ems, and by the time EMS arrived he was feeling better his color had returned in his face. Patient was able to walk and leave store under his own power and didn''t need to be transported.

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