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This is VAERS ID 1736221

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History of Changes from the VAERS Wayback Machine

First Appeared on 10/1/2021

VAERS ID: 1736221
VAERS Form:2
Age:13.0
Sex:Male
Location:Foreign
Vaccinated:2021-08-26
Onset:2021-08-31
Submitted:0000-00-00
Entered:2021-09-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 3003659 / 1 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Erythema, Injection site reaction, Lymphadenopathy, Skin disorder

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': BEMODERNATX, INC.MOD20213

Write-up: This case was received via regulatory authority (Reference number: BE-FAMHP-DHH-N2021-106305) on 17-Sep-2021 and was forwarded to Moderna on 17-Sep-2021. This regulatory authority case was reported by a physician and describes the occurrence of ERYTHEMA, SKIN DISORDER, INJECTION SITE REACTION and LYMPHADENOPATHY in a 13-year-old male patient who received mRNA-1273 (Spikevax) (batch no. 3003659) for COVID-19 vaccination. No Medical History information was reported. On 26-Aug-2021, the patient received first dose of mRNA-1273 (Spikevax) (unknown route) 1 dosage form. On 31-Aug-2021, the patient experienced ERYTHEMA, SKIN DISORDER, INJECTION SITE REACTION and LYMPHADENOPATHY. At the time of the report, ERYTHEMA, SKIN DISORDER, INJECTION SITE REACTION and LYMPHADENOPATHY outcome was unknown. For mRNA-1273 (Spikevax) (Unknown), the reporter did not provide any causality assessments. Concomitant medication was not provided. Treatment information was not provided. Most recent FOLLOW-UP information incorporated above includes: On 17-Sep-2021: The translation document received contains no new information.

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