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From the 11/26/2021 release of VAERS data:

Found 78 cases where Age is 18-or-more-and-under-30 and Vaccine targets COVID-19 (COVID19) and Manufacturer is MODERNA and Patient Died

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Case Details

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VAERS ID: 1783607 (history)  
Form: Version 2.0  
Age: 26.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-08-22
Onset:2021-08-27
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 088D214 / 1 AR / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Autopsy, Cardiomegaly, Death
SMQs:, Cardiac failure (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Autopsy was performed- 8/27/21- doctor said the heart muscle was enlarged and when I called her back to let her know that I was completing this VAERS report she said there was no inflammation but that the heart muscle was thicker than normal possibly due to drug use.
CDC Split Type:

Write-up: On August 27, 2021, was he found deceased in his bed. An autopsy was performed by the medical examiner''s office. Patients'' sister reported that the night before he went to bed and was behaving normally. On Saturday, August 28th, the medical examiner called and informed us that his heart was enlarged. No previous history of enlarged heart had ever been reported and no heart issues had ever been considered in his past.


VAERS ID: 1804633 (history)  
Form: Version 2.0  
Age: 28.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-06-02
Onset:2021-07-11
   Days after vaccination:39
Submitted: 0000-00-00
Entered: 2021-10-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 AR / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Autopsy, Chest pain, Malaise, Myocardial infarction, Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Embolic and thrombotic events, arterial (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-07-11
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Omeprezole/multi-vitamin
Current Illness: None
Preexisting Conditions: Hemochromatosis
Allergies: None
Diagnostic Lab Data: Medical Examiner
CDC Split Type:

Write-up: Was not feeling well one month after vaccine. Had chest pains beginning in July of 2021. Did not go to doctor. Died suddenly on July 11th . It will be 6-9 months for autopsy results. Appeared to be sudden heart attack.


VAERS ID: 1804644 (history)  
Form: Version 2.0  
Age: 26.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:2021-03-16
Onset:2021-09-07
   Days after vaccination:175
Submitted: 0000-00-00
Entered: 2021-10-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002B / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Acute respiratory distress syndrome, Blood culture, COVID-19, COVID-19 pneumonia, Chest X-ray abnormal, Chills, Dyspnoea, Endotracheal intubation, Headache, Hypoperfusion, Hypotension, Hypoxia, Intensive care, Lactic acidosis, Lung disorder, Lung opacity, Mechanical ventilation, Myalgia, Oxygen saturation abnormal, Paralysis, Pneumocystis jirovecii pneumonia, Pyrexia, Respiratory failure, SARS-CoV-2 test positive, Sepsis, Subcutaneous emphysema, Superinfection, Traumatic lung injury
SMQs:, Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (narrow), Angioedema (broad), Asthma/bronchospasm (broad), Lactic acidosis (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Hypersensitivity (broad), Respiratory failure (narrow), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (narrow), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-27
   Days after onset: 20
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: azathioprine, symbicord, rocaltrol, omnicef, zyrtec, d3., cardizem, colace, pulmozyme, iron, fluticasone, IVIG, xopenex, ativan, omeprazole, zofran, miapex, prednisone, sertraline, bactrim
Current Illness: unk.
Preexisting Conditions: ptld, bardet-biedl syndrome, osteoarthritis of hip, CMV, ESRD,
Allergies: ancef, chloral hydrade, contrast, nsaids, vancomycin
Diagnostic Lab Data: 9/25/21 - COVID PCR positive
CDC Split Type:

Write-up: Hospital Course: 27 yo M with Bardet-Biedel syndrome manifesting with transitional AV canal defect s/p repair (followed by Hospital), blindness, developmental delay, multicystic dysplastic kidneys s/p DDKT 11/2/11 and living kidney transplant 1996 on azathioprine and prednisone c/b EBV negative CD20 negative PTLD (dx 10/2016 s/p rituximab in remission), hx of BK and CMV viremia, ?COPD on CPAP, CVID on IVIG every 3 weeks, ON of L hip s/p THR 2019, and DM presenting from OSH with COVID ARDS. Patient lives in group home where several patients had COVID. Of note he is s/p 3 doses of Moderna. On 9/18/21, he was brought to the ER for SOB, headaches, myalgias and chills. He was found to be febrile, hypoxic and COVID positive. He was admitted for COVID pneumonia and developed progressively worsening respiratory status and was ultimately intubated 9/22. He was transferred 9/23 to Hospital (could not be transferred to location due to bed availability). While at Hospital, he continued to have poor respiratory status despite max ventilator settings. He had a rapid response for subcutaneous emphysema, no acute surgical intervention was pursued. He was paralyzed and pronated to improve oxygenation. He also developed a lactic acidosis felt to be 2/2 hypoperfusion from hypotension and underlying sepsis. Per report 1/2 BCx with GPCs, not started on vanc due to hx of red man syndrome. S/p toci x1 9/23, 2 doses of dex 6mg (9/23 - ), 1 dose of remdesivir 100 mg 9/23. He was felt to be needed to transfer to a center with ECMO capabilities, thus was transferred to Hospital. On arrival to the ICU, patient was intubated, sedated and paralyzed. He was satting initially on 78% with improvement subsequently to the 80s. He was subsequently proned. HOSPITAL COURSE 9/24 - 9/27 #COVID ARDS The patient had severe COVID-19 infection and significant risk factors including immunosuppression for kidney transplant and CVID. Presented with hypoxemic respiratory failure, bilateral opacities on CXR with clear injury source and P:F ratio most recently of 56 c/f severe ARDS. Has been getting appropriate PCP ppx but potentially also has other overlying superinfection given immunosuppression, though he has no fever, leukocytosis. He arrived intubated. He was paralyzed, proning, and supported with lung protective ventilation. He was given diuretics, antibiotics and steroids. Evaluated for ECMO but determined not to be a candidate given his baseline lung disease. Infectious disease specialists were consulted and agreed with the management. #Bardet-Biedel syndrome Patient with Bardet-Biedel syndrome with cardiac involvement manifesting as transitional AV canal defect with a primum atrial septal defect and cleft mitral valve as well as an LSVC to the coronary sinus. He underwent surgery in 1994 for repair but was found to have residual subaortic stenosis and required a second surgery in 2007 to reassess subaortic membrane and accessory mitral valve attachment. Follows with Doctor from Hospital.


VAERS ID: 1814760 (history)  
Form: Version 2.0  
Age: 28.0  
Sex: Female  
Location: California  
Vaccinated:2021-08-01
Onset:2021-10-25
   Days after vaccination:85
Submitted: 0000-00-00
Entered: 2021-10-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Arteriogram coronary abnormal, Brain natriuretic peptide increased, Cardiomegaly, Coronary artery thrombosis, Death, Electrocardiogram ST segment elevation, Fibrin D dimer, Myocardial infarction, Troponin
SMQs:, Cardiac failure (broad), Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Pulmonary hypertension (broad), Cardiomyopathy (broad), Other ischaemic heart disease (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-25
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: Unknown
Preexisting Conditions: None known
Allergies: None
Diagnostic Lab Data: Coronary angiography EKG - Positive for ST segment elevation DDimer 1031, Trop 0.053, BNP 1431
CDC Split Type:

Write-up: Approximately 3-5 week after 2nd dose of vaccine patient experience Myocardial Infarction. Angiography revealed diffuse thrombus in coronary arteries and enlarged heart. Pulmonary Embolism is not excluded. Patient expired during angiogram procedure


VAERS ID: 1833098 (history)  
Form: Version 2.0  
Age: 27.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-08-02
Onset:2021-08-04
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-11-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 046B21A / 1 AR / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 009D21A / 2 AR / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Activated partial thromboplastin time prolonged, Alanine aminotransferase increased, Anion gap increased, Aspartate aminotransferase increased, Blood albumin normal, Blood alkaline phosphatase normal, Blood bicarbonate decreased, Blood bilirubin normal, Blood calcium decreased, Blood chloride normal, Blood creatine phosphokinase normal, Blood creatinine increased, Blood glucose normal, Blood lactic acid, Blood magnesium increased, Blood osmolarity normal, Blood pH decreased, Blood phosphorus increased, Blood potassium normal, Blood sodium normal, Blood urea normal, Death, Haematocrit normal, Haemoglobin decreased, Laboratory test, Malaise, Mean cell haemoglobin concentration decreased, Mean cell haemoglobin normal, Mean cell volume increased, N-terminal prohormone brain natriuretic peptide increased, PCO2 increased, PO2 increased, Platelet count normal, Protein total decreased, Red blood cell count decreased, Troponin I increased, Unresponsive to stimuli, White blood cell count normal
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (broad), Liver related investigations, signs and symptoms (narrow), Haematopoietic erythropenia (narrow), Lactic acidosis (broad), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Retroperitoneal fibrosis (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Tumour lysis syndrome (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-09
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: History of substance abuse
Allergies: None
Diagnostic Lab Data: 8/5/2021: Potassium 5.0 mmol/L pH 6.78 pCO2 87 mm HG pO2 312 mmHG HCO3 13 mm/L APTT 44 seconds Glucose 170 mg/dL Sodium 144 mmol/L Potassium 4.7 mmol/L Chloride 102 mmol?L Anion Gap 26 Osmolality calculated 294 mOsm/kg BUN 19 mg/dL Cr 1.30 mg/dL Calcium 8.6 mg/dL Total protein 6.1 g/dL Albumin 3.9 g/dL Total bilirubin 0.3 mg/dL AST 2167 units/L ALT 2250 units/L Alkaline phosphatase 92 units/L Magnesium 2.9 mg/dL Phosphorous 12.7 mg/dL Troponin I 0.383 ng/ml CPK 114 unit/L NT-proBNP 510.0 pg/mL lactic acid 16.5 mmol/L WBC count 8.3 x 10(3)/mcL RBC count 4.67 x 10(6)/mcL Hemoglobin 13.1 g/dL Hematocrit 45.4 percent MCV 97.2 fL MCH 28.1 pg MCHC 28.9 g/dL Platelet count 234 x 10(3)/mcl *Multiple other laboratory values available since he was hospitalized for 4 days - will be cumbersome to manually write them all in here. I am able to provide them at a later date if necessary.
CDC Split Type:

Write-up: According to his mother, Pt received his second dose of the Moderna COVID-19 vaccine on August 2, 2021. Two days later, on August 4, 2021, he complained of not feeling well. He could not provide specific symptoms, but said that it involved his entire body and was not like anything he had ever experienced before. The following day, on August 5, 2021 he was found unresponsive on a train. He was subsequently hospitalized and pronounced deceased on 08/09/2021.


VAERS ID: 1846958 (history)  
Form: Version 2.0  
Age: 20.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-10-13
Onset:2021-10-18
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-11-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Cerebrovascular accident, Myocardial infarction, Thrombosis
SMQs:, Myocardial infarction (narrow), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-03
   Days after onset: 16
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: heart attack, blood clots, stroke


VAERS ID: 1865279 (history)  
Form: Version 2.0  
Age: 25.0  
Sex: Female  
Location: Virginia  
Vaccinated:2021-10-29
Onset:2021-11-06
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-11-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNK / UNK UN / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Luvox, Lemectal
Current Illness: None
Preexisting Conditions: Elhers-Danlos, POTs
Allergies: None
Diagnostic Lab Data: Death
CDC Split Type:

Write-up: Death.


VAERS ID: 1262028 (history)  
Form: Version 2.0  
Age: 26.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-04-10
Onset:2021-04-10
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 3001655 / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Arterial haemorrhage, Hypovolaemic shock
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Hypovolaemic shock conditions (narrow), Dehydration (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: ENALAPRIL; CARVEDILOL
Current Illness: Duchenne muscular dystrophy; Endotracheal intubation; Percutaneous endoscopic gastrostomy; Respiration failure
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: ITMODERNATX, INC.MOD20210

Write-up: IN SHOCK; This regulatory authority case was reported by a physician and describes the occurrence of ARTERIAL HAEMORRHAGE, IN SHOCK and HYPOVOLAEMIC SHOCK, in a 26-year-old male patient who received mRNA-1273 (COVID 19 Vaccine Moderna) (batch no. 3001655) for COVID-19 vaccination. Concurrent medical conditions included Endotracheal intubation, Respiration failure, Percutaneous endoscopic gastrostomy and Duchenne muscular dystrophy. Concomitant products included ENALAPRIL and CARVEDILOL for an unknown indication. On 10-Apr-2021, the patient received first dose of mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) 1 dosage form in total. On 10-Apr-2021, the patient experienced ARTERIAL HAEMORRHAGE (IN SHOCK) (seriousness criterion death) and HYPOVOLAEMIC SHOCK (IN SHOCK) (seriousness criterion death). The patient died on 10-Apr-2021. The reported cause of death was Hypovolaemic shock and Arterial haemorrhage. It is unknown if an autopsy was performed. The action taken with mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) was unknown. For mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular), the reporter did not provide any causality assessments. No treatment information was provided. Company comment: Limited information regarding the events has been provided at this time and a causal relationship cannot be excluded. There is also limited information with regards the conditions captured as history / current conditions and it is unclear if any of these are associated with the recorded events; Reported Cause(s) of Death: Hypovolaemic shock; Arterial haemorrhage


VAERS ID: 1435266 (history)  
Form: Version 2.0  
Age: 24.0  
Sex: Female  
Location: Foreign  
Vaccinated:2021-05-15
Onset:2021-06-09
   Days after vaccination:25
Submitted: 0000-00-00
Entered: 2021-06-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 31946 / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Alanine aminotransferase, Blood creatinine, Blood glucose, C-reactive protein, Cardiac arrest, Fibrin D dimer, Lipase, Pulmonary embolism, Pulmonary infarction, Troponin
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: EFFIPREV [DIENOGEST;ETHINYLESTRADIOL]
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Cardiopulmonary resuscitation; Comments: No medical history was reported by the reporter.
Allergies:
Diagnostic Lab Data: Test Date: 20210609; Test Name: Alanine aminotransferase; Test Result: Inconclusive ; Result Unstructured Data: 106 INTERNATIONAL UNIT(S)-(UNDER 1000) 50/5; Test Date: 20210609; Test Name: Blood creatinine; Test Result: Inconclusive ; Result Unstructured Data: 1.74 MILLIGRAM(S) 1.18/0.55; Test Date: 20210609; Test Name: Blood glucose; Test Result: 321 mg; Result Unstructured Data: 321; Test Date: 20210609; Test Name: C-reactive protein; Test Result: Inconclusive ; Result Unstructured Data: 18.1 MILLIGRAM(S) 5/0; Test Date: 20210609; Test Name: Fibrin D dimer; Test Result: Inconclusive ; Result Unstructured Data: 29.30 MILLIGRAM(S) 0.5/0; Test Date: 20210609; Test Name: Lipase; Test Result: Inconclusive ; Result Unstructured Data: 115 INTERNATIONAL UNIT(S)-(UNDER 100) 67/5; Test Date: 20210609; Test Name: Troponin; Test Result: Inconclusive ; Result Unstructured Data: 878 NANOGRAM(S) 11.6/2.3
CDC Split Type: ITMODERNATX, INC.MOD20212

Write-up: PULMONARY EMBOLISM, PULMONARY INFARCTION, CARDIAC ARREST; PULMONARY EMBOLISM, PULMONARY INFARCTION, CARDIAC ARREST; PULMONARY EMBOLISM, PULMONARY INFARCTION, CARDIAC ARREST; This regulatory authority case was reported by a physician and describes the occurrence of PULMONARY EMBOLISM (PULMONARY EMBOLISM, PULMONARY INFARCTION, CARDIAC ARREST), CARDIAC ARREST (PULMONARY EMBOLISM, PULMONARY INFARCTION, CARDIAC ARREST) and PULMONARY INFARCTION (PULMONARY EMBOLISM, PULMONARY INFARCTION, CARDIAC ARREST) in a 24-year-old female patient who received mRNA-1273 (COVID 19 Vaccine Moderna) (batch no. 31946) for COVID-19 immunisation. No medical history was reported by the reporter. The patient''s past medical history included Cardiopulmonary resuscitation on 09-Jun-2021. Concomitant products included DIENOGEST, ETHINYLESTRADIOL (EFFIPREV [DIENOGEST;ETHINYLESTRADIOL]) for an unknown indication. On 15-May-2021, the patient received first dose of mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) dosage was changed to 1 dosage form. On an unknown date, the patient received dose of mRNA-1273 (COVID 19 Vaccine Moderna) (unknown route) at an unspecified dose. On 09-Jun-2021, the patient experienced PULMONARY EMBOLISM (PULMONARY EMBOLISM, PULMONARY INFARCTION, CARDIAC ARREST) (seriousness criteria death and medically significant), CARDIAC ARREST (PULMONARY EMBOLISM, PULMONARY INFARCTION, CARDIAC ARREST) (seriousness criteria death and medically significant) and PULMONARY INFARCTION (PULMONARY EMBOLISM, PULMONARY INFARCTION, CARDIAC ARREST) (seriousness criteria death and medically significant). The patient died on 09-Jun-2021. The reported cause of death was cardiac arrest. An autopsy was not performed. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On 09-Jun-2021, Alanine aminotransferase: 106 (Inconclusive) 106 INTERNATIONAL UNIT(S)-(UNDER 1000) 50/5. On 09-Jun-2021, Blood creatinine: 1.74 (Inconclusive) 1.74 MILLIGRAM(S) 1.18/0.55. On 09-Jun-2021, Blood glucose (74-106 milligram): 321 milligram (abnormal) 321. On 09-Jun-2021, C-reactive protein: 18.1 (Inconclusive) 18.1 MILLIGRAM(S) 5/0. On 09-Jun-2021, Fibrin D dimer: 29.30 (Inconclusive) 29.30 MILLIGRAM(S) 0.5/0. On 09-Jun-2021, Lipase: 115 (Inconclusive) 115 INTERNATIONAL UNIT(S)-(UNDER 100) 67/5. On 09-Jun-2021, Troponin: 878 (Inconclusive) 878 NANOGRAM(S) 11.6/2.3. The action taken with mRNA-1273 (COVID 19 Vaccine Moderna) (Unknown Route) and mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) was unknown. For mRNA-1273 (COVID 19 Vaccine Moderna) (Unknown Route), the reporter did not provide any causality assessments. Patient was arrived emergency room at 11:24 AM patient was experienced lacking consciousness, pulse and absence of spontaneous breathing and pronounced extreme cyanosis and marble veined. No treatment information was provided by the reporter. For mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular), the reporter did not provide any causality assessments. CT REPORTS AND COPIES OF BLOOD TESTS ARE AVAILABLE, CLINICAL DIARY FROM THE EMERGENCY ROOM AVAILABLE. REQUESTED TODAY DETAILED CLINICAL REPORT TO THE REPORTER This is a case of death in a 24-year-old female patient, that occurred 26 days after receiving first dose of vaccine (Lot number 31946)). Based on the provided information, the patient had cardiac arrest and expired. No further information is expected. Most recent FOLLOW-UP information incorporated above includes: On 16-Jun-2021: Translation uploaded for initial SD containing narrative case summary and further information. On 18-Jun-2021: Follow-up received on 18-JUN-2021 Contains No new information. On 21-Jun-2021: Follow-up received on 21-JUN-2021 Contains No new information.; Sender''s Comments: This is a case of death in a 24-year-old female patient, that occurred 26 days after receiving first dose of vaccine (Lot number 31946)). Based on the provided information, the patient had cardiac arrest and expired. No further information is expected.; Reported Cause(s) of Death: CARDIAC ARREST


VAERS ID: 1463936 (history)  
Form: Version 2.0  
Age: 27.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-05-25
Onset:2021-06-29
   Days after vaccination:35
Submitted: 0000-00-00
Entered: 2021-07-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiac arrest, Death, Embolism, Loss of consciousness, Malaise, Seizure
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Convulsions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (narrow), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-29
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Comments: Past medical history included "homocysteinurie."
Allergies:
Diagnostic Lab Data:
CDC Split Type: BEMODERNATX, INC.MOD20212

Write-up: beeld van asystolie; beeld van embool; tijdens hulpverlening convulsieve bewegingen en bewustzijnsverlies; op 29/06 plots onwel; tijdens hulpverlening convulsieve bewegingen en bewustzijnsverlies; overlijden; This regulatory authority case was reported by a physician and describes the occurrence of DEATH (overlijden), CARDIAC ARREST (beeld van asystolie), LOSS OF CONSCIOUSNESS (tijdens hulpverlening convulsieve bewegingen en bewustzijnsverlies), EMBOLISM (beeld van embool), SEIZURE (tijdens hulpverlening convulsieve bewegingen en bewustzijnsverlies) and MALAISE (op 29/06 plots onwel) in a 27-year-old male patient who received mRNA-1273 (COVID 19 Vaccine Moderna) for COVID-19 vaccination. Past medical history included "homocysteinurie.". On 25-May-2021, the patient received first dose of mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) 1 dosage form. On 23-Jun-2021, received second dose of mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) dosage was changed to 1 dosage form. On 29-Jun-2021, the patient experienced DEATH (overlijden) (seriousness criteria death and medically significant), LOSS OF CONSCIOUSNESS (tijdens hulpverlening convulsieve bewegingen en bewustzijnsverlies) (seriousness criteria death and medically significant), SEIZURE (tijdens hulpverlening convulsieve bewegingen en bewustzijnsverlies) (seriousness criteria death and medically significant) and MALAISE (op 29/06 plots onwel) (seriousness criterion death). On an unknown date, the patient experienced CARDIAC ARREST (beeld van asystolie) (seriousness criteria death and medically significant) and EMBOLISM (beeld van embool) (seriousness criteria death and medically significant). The patient died on 29-Jun-2021. The cause of death was not reported. It is unknown if an autopsy was performed. For mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular), the reporter did not provide any causality assessments. No concomitant medications were provided. No treatment was reported for the events. Translation is pending. Very limited information regarding this events has been provided at this time. Further information has been requested. Further information is not expected.; Sender''s Comments: Very limited information regarding this events has been provided at this time. Further information has been requested. Further information is not expected.; Reported Cause(s) of Death: Unknown cause of death


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