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

This is VAERS ID 1780475

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Case Details

VAERS ID: 1780475 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Washington  
Vaccinated:2021-03-26
Onset:2021-10-05
   Days after vaccination:193
Submitted: 0000-00-00
Entered: 2021-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EP6955 / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute respiratory failure, COVID-19, COVID-19 pneumonia, Endotracheal intubation, Intensive care, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (narrow), 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, 7 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: baby aspirin, atorvastatin, metoprolol succinate, nitroglycerin SL tab PRN, telmisartan
Current Illness:
Preexisting Conditions: history of MI/TIA/CAD, hypertension, hyperlipidemia
Allergies: ACE Inhibitors
Diagnostic Lab Data: COVID status positive on 10/5/21.
CDC Split Type:

Write-up: Patient received Pfizer COVID vaccine on 3/1/21 and 3/26/21. On 10/5/21, patient was admitted to our facility with acute hypoxic failure due to COVID pneumonia (COVID positive). Patient received tocilizumab (10/9), remdesivir (10/5-10/6), and dexamethasone (10/5-current). Patient transferred to CCU on 10/9 and intubated today (10/12).


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