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This is VAERS ID 917835

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/7/2021

VAERS ID: 917835
VAERS Form:2
Age:18.0
Sex:Male
Location:Minnesota
Vaccinated:2020-12-30
Onset:2020-12-31
Submitted:0000-00-00
Entered:2021-01-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Chest pain, Chest X-ray normal, Culture urine negative, Electrocardiogram normal, Electrocardiogram PR shortened, Headache, Malaise, Pain, Pain in extremity, Paraesthesia, Pyrexia, Troponin increased, Immunoglobulin therapy, SARS-CoV-2 test negative, SARS-CoV-2 antibody test

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: COVID 19 Positive sept 82020 Few days of malaise headache ,no respiratory symptoms or chest pain Seen By cardiology at College no ECHO or Troponins as no symptoms of chest pain or SOB
Preexisting Conditions: H/o Peri Myocarditis hospitalized 11/2/19-11/5/2019 with ST elevation and elevated Troponins, normal biventricular function treated with IVIG F/u in 2020 doing well also seen in Cardiology Clinic 12/1/2020 Doing well ,no troponins but Holter placed x 24 hrs normal
Allergies: none H/o Cow''s milk hypersensitivity at 1 mos of age ,no problems with milk now
Diagnostic Lab Data: Troponin 4.56 ng/ml after IVIG 2gm/kg 1/2-1/32021 Gammagard 10% (same as 11/2019)
CDC 'Split Type':

Write-up: Tactile fever ,arm pain, headache and malaise in 24 hrs following injection Next day generalized achiness ,retrosternal chest pain and bilateral forearm tingly pain similar to Nov 2019 and went to Hospital UC,CXR and EKG normal but with short PR interval on EKG ,elevated troponin 3.5 Transferred to hospital troponin 12.1 ng/ml IVIG given SARS IGG positive on admission PCR negative


Changed on 5/7/2021

VAERS ID: 917835 Before After
VAERS Form:2
Age:18.0
Sex:Male
Location:Minnesota
Vaccinated:2020-12-30
Onset:2020-12-31
Submitted:0000-00-00
Entered:2021-01-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Chest pain, Chest X-ray normal, Culture urine negative, Electrocardiogram normal, Electrocardiogram PR shortened, Headache, Malaise, Pain, Pain in extremity, Paraesthesia, Pyrexia, Troponin increased, Immunoglobulin therapy, SARS-CoV-2 test negative, SARS-CoV-2 antibody test

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: COVID 19 Positive sept 82020 Few days of malaise headache ,no respiratory symptoms or chest pain Seen By cardiology at College no ECHO or Troponins as no symptoms of chest pain or SOB
Preexisting Conditions: H/o Peri Myocarditis hospitalized 11/2/19-11/5/2019 with ST elevation and elevated Troponins, normal biventricular function treated with IVIG F/u in 2020 doing well also seen in Cardiology Clinic 12/1/2020 Doing well ,no troponins but Holter placed x 24 hrs normal
Allergies: none H/o Cow''s milk hypersensitivity at 1 mos of age ,no problems with milk now now
Diagnostic Lab Data: Troponin 4.56 ng/ml after IVIG 2gm/kg 1/2-1/32021 Gammagard 10% (same as 11/2019)
CDC 'Split Type':

Write-up: Tactile fever ,arm pain, headache and malaise in 24 hrs following injection Next day generalized achiness ,retrosternal chest pain and bilateral forearm tingly pain similar to Nov 2019 and went to Hospital UC,CXR and EKG normal but with short PR interval on EKG ,elevated troponin 3.5 Transferred to hospital troponin 12.1 ng/ml IVIG given SARS IGG positive on admission PCR negative


Changed on 5/21/2021

VAERS ID: 917835 Before After
VAERS Form:2
Age:18.0
Sex:Male
Location:Minnesota
Vaccinated:2020-12-30
Onset:2020-12-31
Submitted:0000-00-00
Entered:2021-01-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Chest pain, Chest X-ray normal, Culture urine negative, Electrocardiogram normal, Electrocardiogram PR shortened, Headache, Malaise, Pain, Pain in extremity, Paraesthesia, Pyrexia, Troponin increased, Immunoglobulin therapy, SARS-CoV-2 test negative, SARS-CoV-2 antibody test

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: COVID 19 Positive sept 82020 Few days of malaise headache ,no respiratory symptoms or chest pain Seen By cardiology at College no ECHO or Troponins as no symptoms of chest pain or SOB
Preexisting Conditions: H/o Peri Myocarditis hospitalized 11/2/19-11/5/2019 with ST elevation and elevated Troponins, normal biventricular function treated with IVIG F/u in 2020 doing well also seen in Cardiology Clinic 12/1/2020 Doing well ,no troponins but Holter placed x 24 hrs normal
Allergies: none H/o Cow''s milk hypersensitivity at 1 mos of age ,no problems with milk now now
Diagnostic Lab Data: Troponin 4.56 ng/ml after IVIG 2gm/kg 1/2-1/32021 Gammagard 10% (same as 11/2019)
CDC 'Split Type':

Write-up: Tactile fever ,arm pain, headache and malaise in 24 hrs following injection Next day generalized achiness ,retrosternal chest pain and bilateral forearm tingly pain similar to Nov 2019 and went to Hospital UC,CXR and EKG normal but with short PR interval on EKG ,elevated troponin 3.5 Transferred to hospital troponin 12.1 ng/ml IVIG given SARS IGG positive on admission PCR negative

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