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From the 9/17/2021 release of VAERS data:

This is VAERS ID 953557



Case Details

VAERS ID: 953557 (history)  
Form: Version 2.0  
Age: 18.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2020-12-30
Onset:2020-12-31
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / OT

Administered by: Senior Living       Purchased by: ?
Symptoms: Myocarditis
SMQs:, Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (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? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Myocarditis; A spontaneous report was received from a physician, concerning a 18-year-old, male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced myocarditis. The patient''s medical history was not provided. No relevant concomitant medications were reported. On 30 Dec 2020, prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 (lot number: 037K20A) intramuscularly in the left arm for prophylaxis of COVID-19 infection. On 31 Dec 2020, within 24 hours of vaccine administration, the patient develop symptoms of myocarditis and was admitted to the hospital. No treatment information was provided. Action taken with mRNA-1273 in response to the event was not reported. The outcome for the event, myocarditis, was not reported.; Reporter''s Comments: This case concerns an 18-year-old, male, who experienced a serious unexpected event of myocarditis. The event occurred approximately 2 days after first dose of mRNA-1273, Lot# 037K20A administration. No information available regarding medical history and concomitant medications. Very limited information regarding this event has been provided at this time. Based on temporal association between the use of the product and the start date of the event, a causal relationship cannot be excluded.


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