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

This is VAERS ID 1758760

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Case Details

VAERS ID: 1758760 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-03-25
Onset:2021-10-02
   Days after vaccination:191
Submitted: 0000-00-00
Entered: 2021-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9265 / UNK - / -
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EP7534 / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Chest wall mass, Diarrhoea, Pulmonary congestion, SARS-CoV-2 test positive, Vaccine breakthrough infection
SMQs:, Cardiac failure (broad), Pseudomembranous colitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Noninfectious diarrhoea (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

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: CAD, HTN, GERD, Hypothyroidism
Allergies: No Known
Diagnostic Lab Data: Covid + 10/03/2021
CDC Split Type:

Write-up: Breakthrough Covid + 10/3/2021. 90-year-old female with a past medical history significant for irregular heartbeat and osteoporosis presents today for further evaluation and treatment of diarrhea that started a couple days ago. Partially imaged hyperattenuating structure in the right posterolateral chest wall measuring up to 5 cm, which may represent a hematoma. Congestive changes in the lung bases.


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