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From the 11/12/2021 release of VAERS data:

This is VAERS ID 1741118

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Case Details

VAERS ID: 1741118 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-09-01
Onset:2021-09-24
   Days after vaccination:23
Submitted: 0000-00-00
Entered: 2021-09-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 053E21A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute kidney injury, Anticoagulant therapy, COVID-19, Cryotherapy, Deep vein thrombosis, Echocardiogram abnormal, Ejection fraction decreased, Exposure to SARS-CoV-2, General physical health deterioration, Hypoxia, Left ventricular dysfunction, Leg amputation, Peripheral ischaemia
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Asthma/bronchospasm (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), 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, venous (narrow), Thrombophlebitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (narrow), Eosinophilic pneumonia (broad), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-24
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Diabetes
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Admitted on 9/7/2021 with COVID-19 and sever hypoxia. Known COVID contact several days prior. Treated with remdesivir, dexamethasone, ceftriaxone, and azithromycin. Also started on barictnib on 9/9 but stopped due to ARF. Echocardiogram showed EF of 25-50% with moderately severe LV function. Started on heparin and continued throughout hospital stay. DVT in right lower leg. Seen by infectious disease and continued on cefepime and levofloxacin for 14 days. Underwent cryo-amputation of right ischemic lower extremity and then BKA by vascular surgery. Prognosis poor and not improving. Family elected comfort care.


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