Adverse Event Reporting

VAERS ID	1001632
Gender	Unknown
Age
StateCode
Pharmaceutical Company	MODERNA
Lot Number
Number of vaccinations	1
Vaccinated
Onset
Condition	Life Threatening

Symptoms

• Myocarditis

Current Illness

Preexisting Conditions

Medical History/Concurrent Conditions: No adverse event (No reported medical history)

Other Medications

Previous Vaccinations

Allergies

Laboratory Data

Write-up

Myocarditis; A spontaneous report was received from an healthcare professional, regarding a patient who received Moderna's COVID-19 vaccine (mRNA-1273) and experienced Myocarditis.
The patient's medical history was not provided.
No relevant concomitant medications were reported.
On an unknown date, prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 intramuscularly for prophylaxis of COVID-19 infection.
On Unknown date, after receiving the vaccine, the patient experienced Myocarditis.
Treatment for the event was not provided.
Action taken with the second dose of mRNA-1273 in response to the event was not reported.
The outcome for the events, Myocarditis is Unknown.
; Reporter's Comments: This case concerns a patient, who experienced a serious unexpected event of myocarditis.
The event occurred on an unspecified date after first dose of mRNA-1273, lot # unknown.
Treatment was not reported.
Very limited information regarding this event has been provided at this time.
Based on the current available information and temporal association between the use of the product and onset of the event a causal relationship cannot be excluded.