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From the 1/14/2022 release of VAERS data:

This is VAERS ID 1773213

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Case Details

VAERS ID: 1773213 (history)  
Form: Version 2.0  
Age: 16.0  
Sex: Female  
Location: Foreign  
Vaccinated:0000-00-00
Onset:2021-09-22
Submitted: 0000-00-00
Entered: 2021-10-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Anaphylactic reaction
SMQs:, Anaphylactic reaction (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypersensitivity (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:
Allergies:
Diagnostic Lab Data:
CDC Split Type: JPMODERNATX, INC.MOD20213

Write-up: Anaphylactic reaction; This case was received via regulatory authority (Reference number: JP-TAKEDA-2021TJP100278) on 30-Sep-2021 and was forwarded to Moderna on 06-Oct-2021. This case, reported by a health care worker, was received by regulatory authority via Moderna''s adverse reaction reporting site (TASK0021967), and this case, initially reported to the regulatory authority by a physician, was received via the regulatory authority (Ref,v21128310). The patient had an allergic history of house dust. The patient underwent surgery for endocardial defect at the age of 4 years. On an unknown date, the patient received the 1st dose of this vaccine. On an unknown date, body temperature before the vaccination: 35.6 degrees Celsius. On 22-Sep-2021, at 16:44, the patient received the 2nd dose of this vaccine. Immediately after the vaccination, pruritus in the pharynx developed. At 16:59, anaphylaxis developed. The onset was sudden and the symptoms were rapidly progressive. Within several minutes, right chest pain, mild queasy, and abdominal pain developed. Vital signs showed only mild hypertension (BP: 169/81 and P: 62). BP was usually the 120s. The primary care clinic got contacted and ordered an emergency transportation. The patient waited in a first-aid room until transportation. The patient was awake and alert, and there were no agony-like symptoms. At 17:40, the patient was able to transfer alone. The outcome of anaphylaxis was unknown. Follow-up investigation will be made. Company Comment: The event developed after the administration of COVID-19 vaccine mRNA (mRNA 1273) and there is temporal relationship.; Reporter''s Comments: Not reported. The event developed after the administration of COVID-19 vaccine mRNA (mRNA 1273) and there is temporal relationship.; Sender''s Comments: This case concerns a 16-year-old, female patient no previous relevant medical history , who experienced the expected event of Anaphylactic reaction. The event occurred on the same day after the second dose of Spikevax. The rechallenge was not applicable since the event occurred after the second dose. The benefit-risk relationship of Spikevax is not affected by this report.


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