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From the 10/8/2021 release of VAERS data:

This is VAERS ID 1542057



Case Details

VAERS ID: 1542057 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Female  
Location: Connecticut  
Vaccinated:2021-06-15
Onset:2021-07-06
   Days after vaccination:21
Submitted: 0000-00-00
Entered: 2021-08-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 014C21A / 1 UN / UN

Administered by: Other       Purchased by: ?
Symptoms: Aphasia, Bacteraemia, Blood culture, Central venous catheterisation, Computerised tomogram, Culture urine, Death, Disease recurrence, Dyspnoea, Gait inability, Pain, Pemphigoid, Peripheral swelling, Ultrasound scan
SMQs:, Cardiac failure (broad), Severe cutaneous adverse reactions (broad), Anaphylactic reaction (broad), Angioedema (broad), Anticholinergic syndrome (broad), Dementia (broad), Embolic and thrombotic events, venous (narrow), Dystonia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Sepsis (broad), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-07
   Days after onset: 32
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 10 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Calcium supplements, vitamin D3
Current Illness: Bullous Pemphilgoid
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Admitted to hospital 7/9/21 CT scans, urine/ blood cultures, ultrasounds, Moderna 006C21A 2nd dose given at hospital 7/13/21 Central line placement 7/12/21
CDC Split Type:

Write-up: Extremely painful recurrence of bulbous phemphigoid covered most of body. 3.5 weeks after initial vaccine. Required hospitalization 3 times and admission to rehab twice. Unable to walk, difficulty breathing, swollen legs, 2nd hospital. Unable to speak or walk 3rd hosp, ended in death/ bacteremia.


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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1542057

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