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

This is VAERS ID 1787622

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Case Details

VAERS ID: 1787622 (history)  
Form: Version 2.0  
Age: 14.0  
Sex: Female  
Location: Foreign  
Vaccinated:2021-09-23
Onset:2021-09-23
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-10-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Cough, Dyspnoea, Erythema, Lip discolouration, Pallor, Panic reaction, Productive cough
SMQs:, Anaphylactic reaction (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (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? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: FIMODERNATX, INC.MOD20213

Write-up: Pallor facial; Erythema facial; Lip discolouration; Panic reaction; Phlegm; Cough; Breathing difficult; This case was received via Regulatory Agency (Reference number: FI-FIMEA-20215099) on 06-Oct-2021 and was forwarded to Moderna on 06-Oct-2021. This regulatory authority case was reported by a physician and describes the occurrence of in a 14-year-old female patient who received mRNA-1273 (Spikevax) for COVID-19 vaccination. No Medical History information was reported. On 23-Sep-2021, the patient received first dose of mRNA-1273 (Spikevax) (Intramuscular) 1 dosage form. The action taken with mRNA-1273 (Spikevax) (Intramuscular) was unknown. For mRNA-1273 (Spikevax) (Intramuscular), the reporter did not provide any causality assessments. Concomitant product use was not provided Treatment information was not provided Company comment: This case concerns a 14-year-old, female patient with no relevant medical history, who experienced the unexpected events of pallor, erythema, lip discolouration, panic reaction, productive cough, cough and dyspnea. The events of pallor, erythema, lip discolouration, panic reaction, productive cough, cough and dyspnea occurred within the same day of the first dose of mRNA-1273 vaccine administration. The rechallenge was not applicable, as the event occurred within the same day of the first dose of mRNA-1273 vaccine administration. The benefit-risk relationship of mRNA-1273 vaccine is not affected by this report.; Sender''s Comments: This case concerns a 14-year-old, female patient with no relevant medical history, who experienced the unexpected events of pallor, erythema, lip discolouration, panic reaction, productive cough, cough and dyspnea. The events of pallor, erythema, lip discolouration, panic reaction, productive cough, cough and dyspnea occurred within the same day of the first dose of mRNA-1273 vaccine administration. The rechallenge was not applicable, as the event occurred within the same day of the first dose of mRNA-1273 vaccine administration. The benefit-risk relationship of mRNA-1273 vaccine is not affected by this report.


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