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This is VAERS ID 969636

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/29/2021

VAERS ID: 969636
VAERS Form:2
Age:65.0
Sex:Male
Location:Unknown
Vaccinated:2021-01-05
Onset:2021-01-01
Submitted:0000-00-00
Entered:2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Death, Electrocardiogram abnormal, Pain, Pyrexia, Decreased appetite

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-09
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? No
Previous Vaccinations:
Other Medications: METFORMIN; GLIMEPIRIDE; LISINOPRIL; ATORVASTATIN; ASPIRIN (E.C.); METHIMAZOLE; PROPRANOLOL; CILOSTAZOL
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: AV block; Cataracts; Diabetes; Hashimoto''s disease; Hypertension; Hypertriglyceridemia; Premature ventricular contractions (Occasional); Smoker
Allergies:
Diagnostic Lab Data: Test Name: ecg; Result Unstructured Data: AV Block and occasional PVC''s
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: Found dead at home slumped on the floor; Loss of appetite; Body aches; Feverish; A spontaneous report was received from a physician, concerning a 65-years-old male patient, who received Moderna''s COVID-19 Vaccine and experienced feverish, body aches, loss of appetite, and death. The patient''s medical history, as provided by the reporter, included diabetes, hypertension, Hashimoto''s, smoker, cataracts, atrioventricular block, occasional premature ventricular contractions, and hypertriglyceridemia. Concomitant medications reported included metformin, glimepiride, lisinopril, atorvastatin, aspirin, methimazole, propranolol, and cilostazol. On 05 Jan 2021, prior to the onset of events, the patient received the first of two planned doses of mRNA-1273 (lot number 037k20a) for COVID-19 infection prophylaxis. On an unknown date in Jan 2021, some time after receiving the vaccine, the patient was feeling feverish with body aches and loss of appetite. On 09 Jan 2021 at approximately 21:30, the patient was found dead at home slumped on the floor. According to the paramedics, the patient was dead longer than when his wife found him, and no resuscitation was performed. Action taken with mRNA-1273 in response to the events was not applicable. The outcome of the events, feverish, body aches, loss of appetite, was considered resolved. The patient died on 09 Jan 2021. The cause of death was not reported. The reporter assessed the event, death, as not related to Moderna''s COVID-19 Vaccine. The reporter did not provide assessment for the events, feverish and body aches, in relation to Moderna''s COVID-19 Vaccine.; Reporter''s Comments: This case concerns a 65 year old male patient with medical history of diabetes, hypertension, Hashimoto''s, smoker, cataracts, atrioventricular block, occasional premature ventricular contractions, and hypertriglyceridemia, who experienced the serious unexpected event of death, non-serious unexpected event of loss of appetite, and non-serious expected events of fever and body pain. The event of death occurred 5 days after the first dose of mRNA-1273. The events of fever, body pain and loss of appetite occurred an unspecified period of time after the first dose of mRNA-1273. Very limited information regarding these events has been provided at this time. Based on temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded. Definitive causal association is confounded by age and medical history of diabetes, hypertension, Hashimoto''s, smoker, cataracts, atrioventricular block, occasional premature ventricular contractions, and hypertriglyceridemia.


Changed on 5/7/2021

VAERS ID: 969636 Before After
VAERS Form:2
Age:65.0
Sex:Male
Location:Unknown
Vaccinated:2021-01-05
Onset:2021-01-01
Submitted:0000-00-00
Entered:2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Death, Electrocardiogram abnormal, Pain, Pyrexia, Decreased appetite

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-09
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? No
Previous Vaccinations:
Other Medications: METFORMIN; GLIMEPIRIDE; LISINOPRIL; ATORVASTATIN; ASPIRIN (E.C.); METHIMAZOLE; PROPRANOLOL; CILOSTAZOL
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: AV block; Cataracts; Diabetes; Hashimoto''s disease; Hypertension; Hypertriglyceridemia; Premature ventricular contractions (Occasional); Smoker
Allergies:
Diagnostic Lab Data: Test Name: ecg; Result Unstructured Data: AV Block and occasional PVC''s
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: Found dead at home slumped on the floor; Loss of appetite; Body aches; Feverish; A spontaneous report was received from a physician, concerning a 65-years-old male patient, who received Moderna''s COVID-19 Vaccine and experienced feverish, body aches, loss of appetite, and death. The patient''s medical history, as provided by the reporter, included diabetes, hypertension, Hashimoto''s, smoker, cataracts, atrioventricular block, occasional premature ventricular contractions, and hypertriglyceridemia. Concomitant medications reported included metformin, glimepiride, lisinopril, atorvastatin, aspirin, methimazole, propranolol, and cilostazol. On 05 Jan 2021, prior to the onset of events, the patient received the first of two planned doses of mRNA-1273 (lot number 037k20a) for COVID-19 infection prophylaxis. On an unknown date in Jan 2021, some time after receiving the vaccine, the patient was feeling feverish with body aches and loss of appetite. On 09 Jan 2021 at approximately 21:30, the patient was found dead at home slumped on the floor. According to the paramedics, the patient was dead longer than when his wife found him, and no resuscitation was performed. Action taken with mRNA-1273 in response to the events was not applicable. The outcome of the events, feverish, body aches, loss of appetite, was considered resolved. The patient died on 09 Jan 2021. The cause of death was not reported. The reporter assessed the event, death, as not related to Moderna''s COVID-19 Vaccine. The reporter did not provide assessment for the events, feverish and body aches, in relation to Moderna''s COVID-19 Vaccine.; Reporter''s Comments: This case concerns a 65 year old male patient with medical history of diabetes, hypertension, Hashimoto''s, smoker, cataracts, atrioventricular block, occasional premature ventricular contractions, and hypertriglyceridemia, who experienced the serious unexpected event of death, non-serious unexpected event of loss of appetite, and non-serious expected events of fever and body pain. The event of death occurred 5 days after the first dose of mRNA-1273. The events of fever, body pain and loss of appetite occurred an unspecified period of time after the first dose of mRNA-1273. Very limited information regarding these events has been provided at this time. Based on temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded. Definitive causal association is confounded by age and medical history of diabetes, hypertension, Hashimoto''s, smoker, cataracts, atrioventricular block, occasional premature ventricular contractions, and hypertriglyceridemia.


Changed on 5/14/2021

VAERS ID: 969636 Before After
VAERS Form:2
Age:65.0
Sex:Male
Location:Unknown
Vaccinated:2021-01-05
Onset:2021-01-01
Submitted:0000-00-00
Entered:2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Death, Electrocardiogram abnormal, Pain, Pyrexia, Decreased appetite

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-09
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? No
Previous Vaccinations:
Other Medications: METFORMIN; GLIMEPIRIDE; LISINOPRIL; ATORVASTATIN; ASPIRIN (E.C.); METHIMAZOLE; PROPRANOLOL; CILOSTAZOL
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: AV block; Cataracts; Diabetes; Hashimoto''s disease; Hypertension; Hypertriglyceridemia; Premature ventricular contractions (Occasional); Smoker
Allergies:
Diagnostic Lab Data: Test Name: ecg; Result Unstructured Data: AV Block and occasional PVC''s
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: Found dead at home slumped on the floor; Loss of appetite; Body aches; Feverish; A spontaneous report was received from a physician, concerning a 65-years-old male patient, who received Moderna''s COVID-19 Vaccine and experienced feverish, body aches, loss of appetite, and death. The patient''s medical history, as provided by the reporter, included diabetes, hypertension, Hashimoto''s, smoker, cataracts, atrioventricular block, occasional premature ventricular contractions, and hypertriglyceridemia. Concomitant medications reported included metformin, glimepiride, lisinopril, atorvastatin, aspirin, methimazole, propranolol, and cilostazol. On 05 Jan 2021, prior to the onset of events, the patient received the first of two planned doses of mRNA-1273 (lot number 037k20a) for COVID-19 infection prophylaxis. On an unknown date in Jan 2021, some time after receiving the vaccine, the patient was feeling feverish with body aches and loss of appetite. On 09 Jan 2021 at approximately 21:30, the patient was found dead at home slumped on the floor. According to the paramedics, the patient was dead longer than when his wife found him, and no resuscitation was performed. Action taken with mRNA-1273 in response to the events was not applicable. The outcome of the events, feverish, body aches, loss of appetite, was considered resolved. The patient died on 09 Jan 2021. The cause of death was not reported. The reporter assessed the event, death, as not related to Moderna''s COVID-19 Vaccine. The reporter did not provide assessment for the events, feverish and body aches, in relation to Moderna''s COVID-19 Vaccine.; Reporter''s Comments: This case concerns a 65 year old male patient with medical history of diabetes, hypertension, Hashimoto''s, smoker, cataracts, atrioventricular block, occasional premature ventricular contractions, and hypertriglyceridemia, who experienced the serious unexpected event of death, non-serious unexpected event of loss of appetite, and non-serious expected events of fever and body pain. The event of death occurred 5 days after the first dose of mRNA-1273. The events of fever, body pain and loss of appetite occurred an unspecified period of time after the first dose of mRNA-1273. Very limited information regarding these events has been provided at this time. Based on temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded. Definitive causal association is confounded by age and medical history of diabetes, hypertension, Hashimoto''s, smoker, cataracts, atrioventricular block, occasional premature ventricular contractions, and hypertriglyceridemia.

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