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This is VAERS ID 1665576

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First Appeared on 9/10/2021

VAERS ID: 1665576
VAERS Form:2
Age:17.0
Sex:Male
Location:Texas
Vaccinated:2021-02-03
Onset:2021-03-12
Submitted:0000-00-00
Entered:2021-09-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 0077727399/012M / 2 LA / OT

Administered by: Private      Purchased by: ??
Symptoms: Body temperature, Dyspnoea, Oxygen saturation, Pyrexia, Tachycardia, Product administered to patient of inappropriate age

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: MELATONIN; MULTIVITAMINS [VITAMINS NOS]
Current Illness: Allergy (many Airborne allergy); Autism spectrum disorder; Food allergy (some food); Sulfonamide allergy (sulfa(rash))
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Test Name: Body temperature; Test Result: Inconclusive ; Result Unstructured Data: low grade fever; Test Date: 20210313; Test Name: oxygen saturation; Test Result: Inconclusive 92 %; Result Unstructured Data: 92 percent oxygen saturation per pulse oximeter
CDC 'Split Type': USMODERNATX, INC.MOD20212

Write-up: low grade fever; experienced pounding tachycardia; Shortness of breath; inappropriate age at the vaccination; This spontaneous case was reported by a consumer and describes the occurrence of TACHYCARDIA (experienced pounding tachycardia), DYSPNOEA (Shortness of breath), PRODUCT ADMINISTERED TO PATIENT OF INAPPROPRIATE AGE (inappropriate age at the vaccination) and PYREXIA (low grade fever) in a 17-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch nos. 0077727399/012M20A and 0077727399/031A21A) for COVID-19 vaccination. Concurrent medical conditions included Sulfonamide allergy (sulfa(rash)), Allergy (many Airborne allergy), Food allergy (some food) and Autism spectrum disorder since 23-Nov-2003. Concomitant products included MELATONIN and MULTIVITAMINS [VITAMINS NOS] for an unknown indication. On 03-Feb-2021 at 3:00 PM, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 12-Mar-2021 at 12:00 PM, received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) dosage was changed to 1 dosage form. On 12-Mar-2021, after starting mRNA-1273 (Moderna COVID-19 Vaccine), the patient experienced PRODUCT ADMINISTERED TO PATIENT OF INAPPROPRIATE AGE (inappropriate age at the vaccination). On 13-Mar-2021, the patient experienced TACHYCARDIA (experienced pounding tachycardia) and DYSPNOEA (Shortness of breath). On an unknown date, the patient experienced PYREXIA (low grade fever). On 13-Mar-2021, TACHYCARDIA (experienced pounding tachycardia) and DYSPNOEA (Shortness of breath) had resolved. At the time of the report, PRODUCT ADMINISTERED TO PATIENT OF INAPPROPRIATE AGE (inappropriate age at the vaccination) had resolved and PYREXIA (low grade fever) outcome was unknown. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On 13-Mar-2021, Oxygen saturation: 92 percent (Inconclusive) 92 percent oxygen saturation per pulse oximeter. On an unknown date, Body temperature: inconclusive (Inconclusive) low grade fever. No treatment medications were reported. This case was linked to MOD-2021-035571 (Patient Link).

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