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From the 11/26/2021 release of VAERS data:

This is VAERS ID 1775854

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Case Details

VAERS ID: 1775854 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: California  
Vaccinated:2021-06-19
Onset:2021-09-30
   Days after vaccination:103
Submitted: 0000-00-00
Entered: 2021-10-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025C21A / 1 RA / SYR
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 052C21A / 2 RA / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Herpes virus infection, Herpes zoster
SMQs:, Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: No pharmaceuticals. Zinc. Vitamin D. Vitamin C.
Current Illness: None.
Preexisting Conditions: None.
Allergies: None.
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: Herpes and Shingles outbreak simultaneously. Herpes sores on outside of mouth L side and Shingles outbreak on back of L calf.


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