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From the 11/19/2021 release of VAERS data:

This is VAERS ID 1721760

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Case Details

VAERS ID: 1721760 (history)  
Form: Version 2.0  
Age: 59.0  
Sex: Male  
Location: Arizona  
Vaccinated:2021-09-11
Onset:2021-09-12
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-09-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 062E21A / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Gastric ulcer, Muscle spasms, Vomiting
SMQs:, Acute pancreatitis (broad), Dystonia (broad), Gastrointestinal ulceration (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Stomach ulcer (he had been diagnosed with a stomach ulcer in March 2021)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20213

Write-up: Stomach ulcer came back; Had been throwing up and was throwing up again; Back spasms; This spontaneous case was reported by a consumer and describes the occurrence of GASTRIC ULCER (Stomach ulcer came back) in a 59-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch no. 062E21A) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. The patient''s past medical history included Stomach ulcer (he had been diagnosed with a stomach ulcer in March 2021) in 2021. On 11-Sep-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 12-Sep-2021, the patient experienced MUSCLE SPASMS (Back spasms). On 13-Sep-2021, the patient experienced GASTRIC ULCER (Stomach ulcer came back) (seriousness criterion medically significant) and VOMITING (Had been throwing up and was throwing up again). The patient was treated with IBUPROFEN (ADVIL [IBUPROFEN]) for Stomach ulcer, at an unspecified dose and frequency; ALUMINIUM HYDROXIDE GEL, DRIED, MAGNESIUM HYDROXIDE, SIMETICONE (MYLANTA [ALUMINIUM HYDROXIDE GEL, DRIED;MAGNESIUM HYDROXIDE;SIMETICONE]) for Stomach ulcer, at an unspecified dose and frequency and FAMOTIDINE (PEPCID [FAMOTIDINE]) for Stomach ulcer, at an unspecified dose and frequency. At the time of the report, GASTRIC ULCER (Stomach ulcer came back), MUSCLE SPASMS (Back spasms) and VOMITING (Had been throwing up and was throwing up again) outcome was unknown. The action taken with mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) was unknown. concomitant drug details not provided. Company Comment: This case concerns a 59-year-old, male patient with relevant medical history of stomach ulcer, who experienced the unexpected event of stomach ulcer The event occurred approximately 3 days after the first dose of Spikevax. The rechallenge was not applicable, as the event happened after the first dose. The event was considered related to the product per the reporter''s assessment. However, the patient''s medical history and concomitant use of Advil, remains a contributory factor. The benefit-risk relationship of Spikevax is not affected by this report.; Sender''s Comments: This case concerns a 59-year-old, male patient with relevant medical history of stomach ulcer, who experienced the unexpected event of stomach ulcer The event occurred approximately 3 days after the first dose of Spikevax. The rechallenge was not applicable, as the event happened after the first dose. The event was considered related to the product per the reporter''s assessment. However, the patient''s medical history and concomitant use of Advil, remains a contributory factor. The benefit-risk relationship of Spikevax is not affected by this report.


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