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

This is VAERS ID 1761422

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Case Details

VAERS ID: 1761422 (history)  
Form: Version 2.0  
Age: 35.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-03-04
Onset:2021-09-14
   Days after vaccination:194
Submitted: 0000-00-00
Entered: 2021-10-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037A21B / UNK - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011A21A / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Anaemia, B-cell lymphoma, Blood bilirubin increased, Blood glucose increased, COVID-19, Condition aggravated, Cough, Dehydration, Dyspnoea, Evans syndrome, Hypokalaemia, Hyponatraemia, Hypoxia, Leukopenia, Liver function test increased, Pancytopenia, Pneumonia, Pyrexia, SARS-CoV-2 test positive, Splenomegaly, Tachycardia, Vaccine breakthrough infection
SMQs:, Liver related investigations, signs and symptoms (narrow), Haemolytic disorders (narrow), Anaphylactic reaction (broad), Acute pancreatitis (broad), Agranulocytosis (narrow), Asthma/bronchospasm (broad), Haematopoietic cytopenias affecting more than one type of blood cell (narrow), Haematopoietic erythropenia (broad), Haematopoietic leukopenia (narrow), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Biliary system related investigations, signs and symptoms (narrow), Pulmonary hypertension (broad), Hyponatraemia/SIADH (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Malignant lymphomas (narrow), Myelodysplastic syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Haematological malignant tumours (narrow), Infective pneumonia (narrow), Dehydration (narrow), Hypokalaemia (narrow), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (narrow), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-03
   Days after onset: 19
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: Evan''s Syndrome, Cytomegalovirus, B-Cell Lymphoma
Allergies: No Known
Diagnostic Lab Data: Covid + 9/16/2021
CDC Split Type:

Write-up: Breakthrough Covid + 35 year old female with a Past Medical History of Evans Syndrome, Immune Deficiency Disorder, Lymph Node Abscess, B-cell Lymphoma, Cytomegalovirus, Pneumonia, Pneumothorax, Bone Marrow Biopsy, Port, and Lymph Node Biopsy. Admitted to Medical PCU for Low Grade Fever, COVID19, B-Cell Lymphoma, Evans Syndrome, Pneumonia, Splenomegaly, Elevated LFT''s, Elevated Bilirubin, Dehydration, Hypoxemia, Tachycardia, Leukopenia, Anemia, Pancytopenia, Elevated Blood Glucose, Hyponatremia, Hypokalemia, and Questionable Small Lesions within the Liver. Patient was admitted to the hospital for shortness of breath cough and fever. Symptoms have been progressively getting worse over last 1-2 days.


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