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

This is VAERS ID 1463986



Case Details

VAERS ID: 1463986 (history)  
Form: Version 2.0  
Age: 48.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-06-15
Onset:2021-07-01
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-07-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 050C21A / 2 UN / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Hypoxia, Pneumonia, Pyelonephritis, SARS-CoV-2 test negative, Sepsis
SMQs:, Asthma/bronchospasm (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Sepsis (narrow), Opportunistic infections (broad), COVID-19 (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? Yes, 13 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: COVID19 Negative test 6/30/21
CDC Split Type:

Write-up: Patient admitted for sepsis/pyelonephritis/pneumonia/hypoxemia. COVID 19 negative.


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