Adverse Event Reporting
| VAERS ID | 1284937 |
|---|---|
| Gender | Male |
| Age | 81 |
| StateCode | NY |
| Pharmaceutical Company | MODERNA |
| Lot Number | 012L20A |
| Number of vaccinations | 1 |
| Vaccinated | 2021-01-18 |
| Onset | 2021-01-31 |
| Condition | Died |
Symptoms
- Fatigue
- Peripheral swelling
- Pyrexia
- Death
- Body temperature
Current Illness
Diabetic
Preexisting Conditions
Medical History/Concurrent Conditions: Asthma ((but everything was under control).)
Other Medications
Previous Vaccinations
Allergies
Laboratory Data
Test Date: 20210131; Test Name: body temperature; Result Unstructured Data: elevated
Write-up
passed away(death); temperature 99.
7F; tired; left arm swelling; This spontaneous case was reported by a consumer (subsequently medically confirmed) and describes the occurrence of DEATH (passed away(death)) in an 81-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch no.
012L20A) for COVID-19 vaccination.
The occurrence of additional non-serious events is detailed below.
Concurrent medical conditions included Diabetic and Asthma ((but everything was under control).
).
On 18-Jan-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form.
On 31-Jan-2021, the patient experienced PERIPHERAL SWELLING (left arm swelling) and FATIGUE (tired).
On 31-Jan-2021 at 10:30 AM, the patient experienced PYREXIA (temperature 99.
7F).
The patient died on 25-Feb-2021.
The cause of death was not reported.
It is unknown if an autopsy was performed.
At the time of death, PERIPHERAL SWELLING (left arm swelling), PYREXIA (temperature 99.
7F) and FATIGUE (tired) outcome was unknown.
DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On 31-Jan-2021, Body temperature: 99.
7 f (abnormal) elevated.
On 31 Jan 2021, the patient was tired and went to bed early.
At 10:30 pm, the patient's wife reported the patient's temperature as 99.
7 degrees Fahrenheit and was given acetaminophen.
The patient's left arm had swelling.
The patient's son (doctor) prescribed antibiotic for treatment.
On 01 Feb 2021, the patient was taken by ambulance to hospital.
He was at hospital for 24 days and was on a ventilator.
Treatment included Tylenol antibiotic.
Company comment: Very limited information regarding the events has been provided at this time.
Further information has been requested.
.
; Sender's Comments: Very limited information regarding the events has been provided at this time.
Further information has been requested.
.
; Reported Cause(s) of Death: Unknown cause of death