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From the 10/8/2021 release of VAERS data:

This is VAERS ID 960093



Case Details

VAERS ID: 960093 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Foreign  
Vaccinated:2020-12-19
Onset:2020-12-21
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Dizziness, Haematemesis, Loss of consciousness, Pyrexia, SARS-CoV-2 test
SMQs:, Torsade de pointes/QT prolongation (broad), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Gastrointestinal haemorrhage (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2020-12-21
   Days after onset: 0
Permanent Disability? Yes
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: Test Date: 20201116; Test Name: COVID-19 virus test; Result Unstructured Data: Test Result:Negative COVID-19 test
CDC Split Type: GBPFIZER INC2021031481

Write-up: Loss of consciousness; Dizziness; High temperature; Vomiting blood; This is a spontaneous report from a contactable healthcare professional downloaded from the Regulatory Authority WEB (Regulatory Authority number GB-MHRA-WEBCOVID-20201223182431, Safety Report Unique Identifier GB-MHRA-ADR 24546960). A 27-year-old male patient received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE) on 19Dec2020, at single dose, for COVID-19 vaccination. The patient''s medical history and concomitant medications were not reported. The patient underwent a COVID-19 virus test on 16Nov2020 with negative result. The patient experienced vomiting blood on 21Dec2020. On an unspecified date he experienced also loss of consciousness, dizziness and high temperature. All the events were reported as serious as fatal, per hospitalization, disability, medically significant, life threatening. They were reported as serious also per congenital anomaly (no further information provided). Therapeutic measures were taken as a result of all the reported events. The patient died on 21Dec2020. It was not reported if an autopsy was performed. Verbatim EMA narrative: Vomiting blood, vomiting, dizziness, loss of consciousness, fainting, high temperature very often. Follow-up attempts are completed. No further information is expected.; Reported Cause(s) of Death: loss of consciousness; Dizziness; High temperature; Vomiting blood


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