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From the 10/15/2021 release of VAERS data:

This is VAERS ID 974833



Case Details

VAERS ID: 974833 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: North Dakota  
Vaccinated:2021-01-19
Onset:2021-01-24
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Back pain, Blood culture positive, C-reactive protein increased, Cerebral haemorrhage, Chest X-ray, Chest pain, Coagulation test, Computerised tomogram head abnormal, Computerised tomogram thorax normal, Dyspnoea, Endotracheal intubation, Fibrin D dimer increased, Gram stain positive, Haematology test, Laboratory test, Neck pain, Pyrexia, Seizure like phenomena, Unresponsive to stimuli, Urine analysis, White blood cell count increased
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Haemorrhagic central nervous system vascular conditions (narrow), Retroperitoneal fibrosis (broad), Convulsions (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Arthritis (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Sepsis (broad), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: isosorbide mononitrate ER 30mg daily, allopurinol 300mg daily, aspirin 81mg daily, nitroglycerin 0.4mg PRN, rosuvastatin 10mg daily, codine/guaifenesin syrup 5lm PO Q6H PRN, fursemide 40mg BID, levothyroxine 75mg daily, metoprolol succinate
Current Illness: unknown
Preexisting Conditions: CHF, heart murmur, hyperlipidemia, hypertension, aortic valve leak, acute renal failure, history of CABG, AICD and heart stent placement
Allergies: NKA
Diagnostic Lab Data: 1/24/21 0445:hematology, chemistry, coagulation, UA, CXR, Chest CT. 1/24/21 1705: hematology, chemistry, CXR, Head CT.
CDC Split Type:

Write-up: 1/24/21 0445- patient presents to the ED with complaints of neck pain, chest pain, and back pain for about a week. States also feels SOB, intermittent fever with temperature 100.3 on arrival. Patient was worked up for his cardiac type symptoms, found to have elevated WBC and CRP with no explanation. D-Dimer was elevated with CT showing no sign of PE. Patient was sent home from the ED with instructions to follow up with primary care and/or return if s/s worsen. 1/24/21 1705- patient is returned to the ED via ambulance after becoming unresponsive and some seizure like activity. Patient was intubated. Head CT showed large brain bleed that was irreparable and not compatible with life. Patient was also found with positive blood cultures x2 with gram positive cocci in clusters growing after 9 hours.


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