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From the 11/19/2021 release of VAERS data:

This is VAERS ID 916508

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Case Details

VAERS ID: 916508 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Arizona  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2020-12-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Private       Purchased by: ?
Symptoms: Acute kidney injury, Blood creatinine increased, Blood glucose increased, Blood potassium decreased, C-reactive protein increased, COVID-19 pneumonia, Chest X-ray abnormal, Cough, Decreased appetite, Hyperglycaemia, Hypokalaemia, Hypoxia, Intensive care, Malaise, Pneumonia, SARS-CoV-2 test positive, Troponin increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Myocardial infarction (narrow), 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 (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (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, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: escitalopram 10mg QD lisinopril 10mg QD trazodone 100mg QHS atorvastatin 20mg HS bupropion XL 150mg QD empagliflozin 10mg QD insulin 70/30 kwikpen 22units QAM, 20units QPM
Current Illness: COVID + pneumonia (this was undiagnosed at the time of vaccination b/c he had no symptoms upon vaccination prescreening)
Preexisting Conditions: Hypertension Benign prostatic hyperplasia Depression Uncontrolled diabetes mellitus Hyperlipidemia Latent tuberculosis
Allergies: Benzoin tincture
Diagnostic Lab Data: Pt is an 81 year old male with pmedhx of uncontrolled DM2, HTN, depression, BPH, HLD, insomnia, hx of EtOH w/d seizure. Pt states he called EMS because he had not had an appetite for 3 days and had not been eating much. EMS noted pt''s SpO2 was 62% on RA, increased to 90s after several min on 15L NRB. Pt denied shortness of breath at any point, denied sweats/chills, HA, vomiting/diarrhea. He did states he had a cough in addition to loss of appetite. CXR with finding of BL PNA, Abbott COVID + in ER. CRP 31.4. Pt was also noted to be hyperglycemic with glucose 408, trop elevated 0.12 but without chest pain, AKI creat 1.4 with baseline 0.9, and hypokalemic with K 3.0. Pt admitted to ICU for COVID related hypoxia. Notably, pt was vaccinated for COVID 19 with 1st Moderna vaccine today in am. Pt states he told screeners he felt well because he did not have shortness of breath or body aches. As of 12/31/2020, patient is still hospitalized in ICU.
CDC Split Type:

Write-up: Pt received 1st dose of Moderna vaccine in am at COVID vaccination clinic. On presentation to clinic he stated he was feeling well. Pt was brought to ER in pm with hypoxic, requiring 15L supplemental O2. Per pt''s family, pt was not feeling well for the last couple of days but didn''t think it was related to COVID. Abbott COVID + in ER. Possible vaccine reaction, though seems unlikely.

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