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From the 10/8/2021 release of VAERS data:

This is VAERS ID 904504



Case Details

VAERS ID: 904504 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:2020-12-19
Onset:2020-12-19
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2020-12-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Anaphylactic reaction, Angioedema, Throat tightness
SMQs:, Anaphylactic reaction (narrow), Angioedema (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Oropharyngeal allergic conditions (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Rosuvastatin, meloxicam, omeprazole, vitamin D
Current Illness: None
Preexisting Conditions: High cholesterol, psoriasis, gerd
Allergies: Shellfish, iodine
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Throat closure (angioedema/anaphylaxis) requiring ambulance transport to Hospital emergency room and stay IV infusion of Benedryl, solumedrol, and Pepcid with excellent results. Observed twelve hours, then discharged.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=904504

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