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From the 1/14/2022 release of VAERS data:

This is VAERS ID 1729740

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Case Details

VAERS ID: 1729740 (history)  
Form: Version 2.0  
Age: 16.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-09-11
Onset:2021-09-11
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-09-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Anaphylactic reaction, Presyncope, Visual impairment
SMQs:, Anaphylactic reaction (narrow), Anticholinergic syndrome (broad), Anaphylactic/anaphylactoid shock conditions (narrow), Glaucoma (broad), Optic nerve disorders (broad), Lens disorders (broad), Retinal disorders (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (narrow), Hypoglycaemia (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, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: JPMODERNATX, INC.MOD20213

Write-up: Vasovagal reflex; Dimmed vision; Possibility of anaphylaxis; This case was received via regulatory authority (Reference number: 2021TJP093278) on 13-Sep-2021 and was forwarded to Moderna on 23-Sep-2021. This case, reported by a vaccinator (other than a physician), was received by regulatory authority via Moderna''s adverse reaction reporting site (TASK0021689), and reported to the regulatory authority by a vaccinator (other than a physician), was received via the regulatory authority (Ref, v21126586). On 11-Sep-2021, at 11:00, the patient received the 1st dose of this vaccine. At 11:05, anaphylaxis possibly developed suddenly. At 11:30, vasovagal reflex developed. Queasy and dimmed vision were noted. Lactated ringer''s solution 500 mL, d-chlorpheniramine maleate 1A, and famotidine 1A were administered in bed. Improvement was confirmed, and when the patient walked home, queasy developed again. Adrenaline 0.3 mg was injected intramuscularly in bed, but the symptoms did not improve. The patient was raced to a hospital and was hospitalized. On 12-Sep-2021, the patient had queasy but was discharged from the hospital at the patient''s request. On 13-Sep-2021, it was confirmed that the symptoms were resolving. The outcome of possibility of anaphylaxis, vasovagal reflex, and dimmed vision was reported as resolving. Follow-up investigation will be made. Company Comment: The events developed after the administration of COVID-19 vaccine mRNA (mRNA 1273) and there is temporal relationship. Company Comment: This case concerns a 16-year-old, male patient with no medical history, who experienced the expected event of Anaphylactic reaction. The event occurred immediately within 30 minutes after the first dose of mRNA-1273 (Moderna COVID-19 Vaccine). The patient also experienced serious events of Presyncope and Visual impairment. Event seriousness assessed as per Regulatory Authority reporting. The rechallenge was not applicable. The reporter assessed the events as possible. The benefit-risk relationship of mRNA-1273 (Moderna COVID-19 Vaccine) is not affected by this report.; Sender''s Comments: This case concerns a 16-year-old, male patient with no medical history, who experienced the expected event of Anaphylactic reaction. The event occurred immediately within 30 minutes after the first dose of mRNA-1273 (Moderna COVID-19 Vaccine). The patient also experienced serious events of Presyncope and Visual impairment. Event seriousness assessed as per Regulatory Authority reporting. The rechallenge was not applicable. The reporter assessed the events as possible. The benefit-risk relationship of mRNA-1273 (Moderna COVID-19 Vaccine) is not affected by this report.


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