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

This is VAERS ID 1901096

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Case Details

VAERS ID: 1901096 (history)  
Form: Version 2.0  
Age: 13.0  
Sex: Female  
Location: Utah  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013F21A / 3 LA / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Asthenia, Chills, Flushing, Inappropriate schedule of product administration, Influenza like illness, Injection site pain, Muscular weakness, Myalgia, Pain, Product administered to patient of inappropriate age, Pyrexia, Vaccination complication, Vaccination site pain
SMQs:, Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (broad), Peripheral neuropathy (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalopathy/delirium (broad), Extravasation events (injections, infusions and implants) (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Tendinopathies and ligament disorders (broad), Medication errors (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (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? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20213

Write-up: Flush; Extreme flu like symptoms; Weakness; Other body aches; chills; Tenderness at inection site; Muscle pain; Local pain at injection site; Fever; Severe reaction/significant side effects; Muscle weakness; Achiness; Inappropriate schedule of vaccine administered; 13 year old given Moderna booster; This spontaneous case was reported by a pharmacist and describes the occurrence of VACCINATION COMPLICATION (Severe reaction/significant side effects), MUSCULAR WEAKNESS (Muscle weakness), PAIN (Achiness), FLUSHING (Flush) and INFLUENZA LIKE ILLNESS (Extreme flu like symptoms) in a 13-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch no. 013F21A) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. Previously administered products included for COVID-19 vaccination: Pfizer from 22-Jul-2021 to 13-Aug-2021. Past adverse reactions to the above products included No adverse event with Pfizer. On 15-Nov-2021 at 9:00 PM, the patient received third dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On 15-Nov-2021, the patient experienced INAPPROPRIATE SCHEDULE OF PRODUCT ADMINISTRATION (Inappropriate schedule of vaccine administered). 15-Nov-2021, the patient experienced PRODUCT ADMINISTERED TO PATIENT OF INAPPROPRIATE AGE (13 year old given Moderna booster). On 16-Nov-2021, the patient experienced VACCINATION COMPLICATION (Severe reaction/significant side effects), MUSCULAR WEAKNESS (Muscle weakness), INJECTION SITE PAIN (Tenderness at inection site), MYALGIA (Muscle pain), VACCINATION SITE PAIN (Local pain at injection site) and PYREXIA (Fever). 16-Nov-2021, the patient experienced PAIN (Achiness). 16-Nov-2021, the patient experienced CHILLS (chills). On 16-Nov-2021 at 1:00 PM, the patient experienced INFLUENZA LIKE ILLNESS (Extreme flu like symptoms), ASTHENIA (Weakness) and PAIN (Other body aches). On 17-Nov-2021, the patient experienced FLUSHING (Flush). The patient was treated with IBUPROFEN at an unspecified dose and frequency. On 15-Nov-2021, INAPPROPRIATE SCHEDULE OF PRODUCT ADMINISTRATION (Inappropriate schedule of vaccine administered) and PRODUCT ADMINISTERED TO PATIENT OF INAPPROPRIATE AGE (13 year old given Moderna booster) had resolved. On 18-Nov-2021, INFLUENZA LIKE ILLNESS (Extreme flu like symptoms), ASTHENIA (Weakness), PAIN (Other body aches) and PYREXIA (Fever) had resolved. At the time of the report, VACCINATION COMPLICATION (Severe reaction/significant side effects), MUSCULAR WEAKNESS (Muscle weakness), PAIN (Achiness), CHILLS (chills), MYALGIA (Muscle pain) and VACCINATION SITE PAIN (Local pain at injection site) was resolving and FLUSHING (Flush) and INJECTION SITE PAIN (Tenderness at inection site) outcome was unknown. For mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown), the reporter did not provide any causality assessments. No concomitant medication were provided. Patient was supposed to get a flu shot but was given with the Moderna Booster .25mLs instead. On 16Nov2021 Patient had significant side effects about 16 hours after vaccination. Patient reported that ,felt like bones were disintegrating. Most recent FOLLOW-UP information incorporated above includes: On 18-Nov-2021: Significant Follow-up received on 18-NOV-2021 contains events i.e. local pain at injection site, achiness,severe reaction/severe normal, fever, chills, bones were disintegrating ,muscle weakness and pain,ocal pain at injection site,flush were added and treatment drug Ibuprofen added On 19-Nov-2021: Significant follow-up received on 19-NOV-2021,contains patient ethic details and race information, and events i.e.extreme flu like symptoms, body ache were added and event outcome for chills, fever, weakness were updated to recovered


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