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This is VAERS ID 1757964

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History of Changes from the VAERS Wayback Machine

First Appeared on 10/8/2021

VAERS ID: 1757964
VAERS Form:2
Age:17.0
Sex:Male
Location:Foreign
Vaccinated:2021-07-20
Onset:0000-00-00
Submitted:0000-00-00
Entered:2021-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Death, Myocarditis

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
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: Death; Bilateral myocarditis; This spontaneous case was reported by a consumer and describes the occurrence of DEATH (Death) and MYOCARDITIS (Bilateral myocarditis) in a 17-year-old male patient who received mRNA-1273 (Spikevax) for COVID-19 vaccination. No Medical History information was reported. On 20-Jul-2021, the patient received dose of mRNA-1273 (Spikevax) (unknown route) 1 dosage form. On an unknown date, the patient experienced DEATH (Death) (seriousness criteria death and medically significant) and MYOCARDITIS (Bilateral myocarditis) (seriousness criterion medically significant). The patient died on an unknown date. The cause of death was not reported. It is unknown if an autopsy was performed. At the time of death, MYOCARDITIS (Bilateral myocarditis) outcome was unknown. Concomitant product was not provided. Treatment medication was not reported. Patient died at 17 was reported. Company Comment: This case concerns a 17-year-old male patient with no reported medical history, who experienced the unexpected, serious event of death and expected and AESI event of myocarditis. Time to onset from vaccination was not reported. Date of death was not reported and autopsy report is not available. The rechallenge was not applicable, since vaccination dose number were not specified. The benefit-risk relationship of Spikevax is not affected by this report. Further information is expected. This case was linked to MOD-2021-332861 (Patient Link).; Sender''s Comments: This case concerns a 17-year-old male patient with no reported medical history, who experienced the unexpected, serious event of death and expected and AESI event of myocarditis. Time to onset from vaccination was not reported. Date of death was not reported and autopsy report is not available. The rechallenge was not applicable, since vaccination dose number were not specified. The benefit-risk relationship is not affected by this report. Further information is expected.; Reported Cause(s) of Death: Unknown cause of death

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