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

This is VAERS ID 1783376

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Case Details

VAERS ID: 1783376 (history)  
Form: Version 2.0  
Age: 15.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-08-13
Onset:2021-09-14
   Days after vaccination:32
Submitted: 0000-00-00
Entered: 2021-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 3004954 / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Asthenia, C-reactive protein, Chest discomfort, Chest pain, Echocardiogram, Ejection fraction, Electrocardiogram, Malaise, Myocarditis, Troponin T, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

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: Test Date: 202109; Test Name: C-reactive protein; Result Unstructured Data: 68 (increased) mg/mL; Test Date: 202109; Test Name: Echocardiography; Result Unstructured Data: OBS slightly decreased left ventricle function; Test Date: 202109; Test Name: Ejection fraction; Result Unstructured Data: 45 (%percent); Test Date: 202109; Test Name: EKG; Result Unstructured Data: Monstrous ST-elevations; Test Date: 202109; Test Name: Troponin T; Result Unstructured Data: 2289.3 (increased) ng/L
CDC Split Type: DKMODERNATX, INC.MOD20213

Write-up: Chest pressure; Chest pain; General malaise; Vomiting; Weakness; Perimyocarditis; This case was received via a regulatory authority (Reference number: DK-DKMA-ADR 25984621) on 05-Oct-2021 and was forwarded to Moderna on 05-Oct-2021. This regulatory authority case was reported by a physician and describes the occurrence of CHEST DISCOMFORT (Chest pressure), CHEST PAIN (Chest pain), MALAISE (General malaise), VOMITING (Vomiting), ASTHENIA (Weakness) and MYOCARDITIS (Perimyocarditis) in a 15-year-old male patient who received mRNA-1273 (Spikevax) (batch nos. 3004954 and 3004954) for COVID-19 immunisation. No Medical History information was reported. On 13-Aug-2021, the patient received first dose of mRNA-1273 (Spikevax) (Intramuscular) 1 dosage form. On 13-Sep-2021, received second dose of mRNA-1273 (Spikevax) (Intramuscular) dosage was changed to 1 dosage form. On 14-Sep-2021, the patient experienced CHEST DISCOMFORT (Chest pressure) (seriousness criterion hospitalization), CHEST PAIN (Chest pain) (seriousness criterion hospitalization), MALAISE (General malaise) (seriousness criterion hospitalization), VOMITING (Vomiting) (seriousness criterion hospitalization), ASTHENIA (Weakness) (seriousness criterion hospitalization) and MYOCARDITIS (Perimyocarditis) (seriousness criteria hospitalization and medically significant). At the time of the report, CHEST DISCOMFORT (Chest pressure), CHEST PAIN (Chest pain), MALAISE (General malaise), VOMITING (Vomiting), ASTHENIA (Weakness) and MYOCARDITIS (Perimyocarditis) was resolving. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): In September 2021, C-reactive protein: high (High) 68 (increased) mg/mL. In September 2021, Echocardiogram: abnormal (abnormal) OBS slightly decreased left ventricle function. In September 2021, Ejection fraction: 45 (abnormal) 45 (%percent). In September 2021, Electrocardiogram: abnormal (abnormal) Monstrous ST-elevations. In September 2021, Troponin T: 2289.3 (High) 2289.3 (increased) ng/L. For mRNA-1273 (Spikevax) (Intramuscular), the reporter did not provide any causality assessments. Concomitant medications was not reported. Treatment history was not reported. Company Comment: This case concerns a 15 year old male with no reported medical history , who experienced expected event of myocarditis and other unexpected events of chest pain, chest pressure, weakness , asthenia and malaise . These events occurred 2 days after vaccination with the 2nd dose of mRNA-1273 (Spikevax) and 1 month and 2 days post vaccination with the 1st dose. The rechallenge for this case is not applicable. The benefit risk relationship of mRNA-1273 ( Spikevax) is not affected by this report.; Sender''s Comments: This case concerns a 15 year old male with no reported medical history , who experienced expected event of myocarditis and other unexpected events of chest pain, chest pressure, weakness , asthenia and malaise . These events occurred 2 days after vaccination with the 2nd dose of mRNA-1273 (Spikevax) and 1 month and 2 days post vaccination with the 1st dose. The rechallenge for this case is not applicable. The benefit risk relationship of mRNA-1273 ( Spikevax) is not affected by this report.


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