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

This is VAERS ID 959591

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Case Details

VAERS ID: 959591 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Colorado  
Vaccinated:2020-12-22
Onset:2020-12-31
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Acute kidney injury, Asthenia, Blood chloride decreased, Blood glucose normal, Blood sodium decreased, Blood urea increased, Full blood count, Hyporesponsive to stimuli, Hypotension, Lethargy, Metabolic function test, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), 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), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hyponatraemia/SIADH (narrow), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-17
   Days after onset: 17
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 14 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Allopurinol 300mg, Atrovastatin 80mg, CaroSpir Suspension 25mg/5mL, Clopidogrel Bisulfate 75mg, Duloxetine HCL 30mg, Insulin- Lantus 14 units, Levothyroxine 137mcg, Lidocaine patch 5%, Potassium Chloride ER 20MEQ, Prilosec DR 40mg, Psylliu
Current Illness: He was treated for pneumonia and C-Diff at the beginning of December. He had abnormal blood work with elevated BUN and WBC on 12/31 and 1/3/21. Appetite was fluctuating and recently began increase medication for depression. Decrease responsiveness sent to ER on 1/4/2021.
Preexisting Conditions: oxygen dependent, metabolic encephalopathy, atrial fibrillation, hypertension, diabetes, cardiac pacemaker, depression, congestive heart failure, obesity, hypothyroidism, sleep apnea, hyperlipidemia, cushing''s disease.
Allergies: Amoxicillin, Ceftriaxone, Lisinopril, Niacin, Pilglitazone, Rosiglitazone, Penicillins
Diagnostic Lab Data: BMP and CBC done 1/3/2021 - low sodium 131, chloride 94, Glucose 131, BUN 80, WBC 18.9
CDC Split Type:

Write-up: Resident has increase weakness and lethargy with abnormal labs. He was transferred to the ER. He was admitted to the hospital and treated for worsening AKI and hypotension.


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