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

This is VAERS ID 998422



Case Details

VAERS ID: 998422 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-01-30
Onset:2021-01-31
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Alanine aminotransferase normal, Aspartate aminotransferase normal, Blood albumin, Blood alkaline phosphatase normal, Blood bilirubin normal, Blood calcium, Blood chloride normal, Blood creatine phosphokinase MB decreased, Blood creatine phosphokinase MB increased, Blood creatine phosphokinase normal, Blood creatinine increased, Blood glucose increased, Blood lactic acid, Blood lactic acid normal, Blood potassium normal, Blood sodium decreased, Blood urea increased, Blood urine absent, Brain natriuretic peptide normal, Carbon dioxide decreased, Cerebral atrophy, Chest X-ray normal, Computerised tomogram head normal, Dehydration, Full blood count normal, Haematocrit normal, Haemoglobin decreased, Hypophagia, Hyporesponsive to stimuli, Immunology test, Mental status changes, Metabolic function test, Muscular weakness, Platelet count normal, Procalcitonin normal, Protein urine, Pyrexia, SARS-CoV-2 test negative, Somnolence, Specific gravity urine normal, Troponin I normal, White blood cell count normal, pH urine normal
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Haematopoietic erythropenia (broad), Peripheral neuropathy (broad), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Dementia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hyponatraemia/SIADH (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Proteinuria (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-21
   Days after onset: 21
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Amlodipine 5 mg daily; cimetidine 300 mg 4 times a day; donepezil 10 mg daily; fluticasone nasal spray daily; gabapentin 600 mg 3 times a day; glipizide 2.5 mg daily; losartan 100 mg daily; memantine10 mg twice a day; metformin 500 mg twice
Current Illness: None
Preexisting Conditions: Type II diabetes, hypertension, hypothyroidism, GERD, hyperlipidemia, early dementia.
Allergies: None
Diagnostic Lab Data: 2/2: WBC 8.7, H/H 13.6/40.5; Plt 185,000; Glucose 173, BUN 23, creatinine 1.5, Na 135, K 4.7, Cl 102, CO2 22, Ca 8.3, Tot protein 6.1, albumin 3.5, ALP 71, AST, 20, ALT 12, Tot bili 0.30, BNP 24, CPK 131, CKMB 1.8, troponin i <0.06. SARS FIA negative. UA: sp gr 1.025, pH 7.0 1+ protein, neg blood o/w normal. 2/3: WBC 8.4, H/H 12.4/36; BUN 18, creat1.1 CT head normal for age; CXR no evidence of infection.
CDC Split Type:

Write-up: patient developed progressive diffuse muscle weakness, altered mental status including excessive drowsiness, decreased oral intake starting on 1/31/2021. Symptoms continued to worsen overnight and he was evaluated in the emergency room on 2/2/2021 and admitted with dehydration and altered mental status. He was aggressively hydrated overnight, but showed persistent diffuse muscle weakness, altered mental status with decreased responsiveness progressing, but no focal neurological findings noted. CT scan of the head on 3/3/2021 showed no findings other than age-related diffuse cerebral atrophy. The patient did spike a fever to 103 on the morning of 2/3/2021. CBC, CMP, procalcitonin and lactic acid levels remained normal. He remains hospitalized in stable condition as of 2/3/2021 @1300.


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