Adverse Event Reporting

VAERS ID	1405284
Gender	Male
Age	74
StateCode	IL
Pharmaceutical Company	MODERNA
Lot Number	007M20A
Number of vaccinations	1
Vaccinated	2021-01-28
Onset	2021-03-06
Condition	Died

Symptoms

• Chills
• Pain
• Anosmia
• Ageusia
• Death

Current Illness

Preexisting Conditions

Other Medications

Previous Vaccinations

Allergies

Laboratory Data

Write-up

loss sense of taste; Lost sense of smell; pain in body; chills; Patient died; This spontaneous case was reported by a patient family member or friend and describes the occurrence of DEATH (Patient died) in a 74-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch nos.
030M20A and 007M20A) for COVID-19 vaccination.
The occurrence of additional non-serious events is detailed below.
No Medical History information was reported.
On 28-Jan-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form.
On 21-Feb-2021, received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) dosage was changed to 1 dosage form.
On an unknown date, the patient experienced AGEUSIA (loss sense of taste), ANOSMIA (Lost sense of smell), PAIN (pain in body) and CHILLS (chills).
The patient died on 06-Mar-2021.
The cause of death was not reported.
It is unknown if an autopsy was performed.
At the time of death, AGEUSIA (loss sense of taste), ANOSMIA (Lost sense of smell), PAIN (pain in body) and CHILLS (chills) was resolving.
Concomitant medications were not reported.
No treatment information was provided.
Based on the current available information and temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded.
This case was linked to MOD-2021-201255 (Patient Link).
; Sender's Comments: Based on the current available information and temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded.
; Reported Cause(s) of Death: unknown casue of death