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

This is VAERS ID 927938

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Case Details

VAERS ID: 927938 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Hawaii  
Vaccinated:2020-12-29
Onset:2020-12-30
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Chest X-ray abnormal, Pneumonia, Pyrexia, SARS-CoV-2 test positive
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (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? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Received Moderna vaccine on 12/29/2020. 12/30/2020 fever of 100.4 Tylenol given and monitored and fever went down. 12/31/2020 Chest x-ray completed and sent to the hospital and admitted with pneumonia. 1/3/2021 reported by the hospital that Covid-19 results were positive. He had had Covid-19 positive results back on 11/4/2020 prior to vaccine.


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