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

This is VAERS ID 1782695

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Case Details

VAERS ID: 1782695 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-03-29
Onset:2021-10-09
   Days after vaccination:194
Submitted: 0000-00-00
Entered: 2021-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006B21A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute respiratory failure, Blood sodium decreased, Blood urea increased, COVID-19, COVID-19 pneumonia, Chest X-ray abnormal, Cough, Dyspnoea, Dyspnoea exertional, Exposure to SARS-CoV-2, Fatigue, Fibrin D dimer, Lung infiltration, Oxygen saturation, Pain, Pyrexia, SARS-CoV-2 test positive, Sick relative, Vaccine breakthrough infection, White blood cell count increased
SMQs:, Acute renal failure (broad), Anaphylactic reaction (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (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), Pulmonary hypertension (broad), Hyponatraemia/SIADH (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (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? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: UNKNOWN
Current Illness: UNKNOWN
Preexisting Conditions: ALZHEIMER''S, CAD, GERD,HYPERLIPIDEMIA
Allergies: APPLE, PEACH FLAVOR AND TOMATO
Diagnostic Lab Data: SAR-COV2 NAAT-POSITIVE, CXR-BILATERAL PULMONARY INFILTRATES, 02 SAT 85% ON ROOM AIR. D-DIMER-1.50, WBC-15.9, CO2-19, BUN-24, SODIUM-133,
CDC Split Type:

Write-up: BREAKTHROUGH HOSPITALIZATION CASE. VACCINATED FOR COVID-19 IN MARCH 2021. 10/9/21-STARTED HAVING SOB AND FATIGUE INCREASING IN SEVERITY, THEN HE PRESENTED IN THE ER ON 10/10/21. HE C/O HAVING BODY ACHES, FATIGUE, NON-PRODUCTIVE COUGH AND SOB WITH EXERTION. TEMP 102.7F. HIS WIFE TESTED POSITIVE FOR COVID-19 SEVERAL DAYS BEFORE. HIS TEST WAS NEGATIVE AT THAT TIME. HE WAS TESTED AGAIN IN THE ER AND WAS POSITIVE FOR COVID-19. HE IS A FORMER SMOKER. HE WAS STARTED ON 2L OF O2. HE WAS DIAGNOSED WITH ACUTE HYPOXEMIC RESPIRATORY FAILURE, COVID-19 VIRUS INFECTION AND PNEUMONIA DUE TO COVID-19 VIRUS.


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