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This is VAERS ID 953557

History of Changes from the VAERS Wayback Machine

First Appeared on 4/1/2021

VAERS ID: 953557
VAERS Form:2
Age:18.0
Sex:Male
Location:Minnesota
Vaccinated:2020-12-30
Onset:2020-12-31
Submitted:0000-00-00
Entered:2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / OT

Administered by: Senior Living      Purchased by: ??
Symptoms: Myocarditis

Life Threatening? No
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:     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.


Changed on 5/7/2021

VAERS ID: 953557 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:2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / OT

Administered by: Senior Living      Purchased by: ??
Symptoms: Myocarditis

Life Threatening? No
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:     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.


Changed on 5/14/2021

VAERS ID: 953557 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:2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / OT

Administered by: Senior Living      Purchased by: ??
Symptoms: Myocarditis

Life Threatening? No
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:     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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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=953557&WAYBACKHISTORY=ON


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