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

This is VAERS ID 1602904



Case Details

VAERS ID: 1602904 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-04-12
Onset:2021-04-14
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-08-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 206A21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Cardiac arrest, Cardiac stress test, Computerised tomogram, Condition aggravated, Echocardiogram, Fibrin D dimer increased, Hypertension, Renal failure, Thrombosis
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (broad), Haemorrhage laboratory terms (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad), Acute central respiratory depression (broad), Hypertension (narrow), Cardiomyopathy (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-07-27
   Days after onset: 104
Permanent Disability? Yes
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 15 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Welbutrin
Current Illness: none
Preexisting Conditions: Hypertension
Allergies: no
Diagnostic Lab Data: HIgh D-dimer, CT scans, echo heart, stress test and others.
CDC Split Type:

Write-up: Patient developed high D-dimer and blood clots immediately after vaccination. Kidney failure followed shortly thereafter. Went into hypertensive cardiac arrest approximately 3 weeks later. All started with vaccination.


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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1602904

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