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

This is VAERS ID 1336767

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Case Details

VAERS ID: 1336767 (history)  
Form: Version 2.0  
Age: 19.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-04-03
Onset:2021-04-30
   Days after vaccination:27
Submitted: 0000-00-00
Entered: 2021-05-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: School       Purchased by: ?
Symptoms: Bradycardia, Cardiac arrest, Cardiogenic shock, Dizziness, Myocarditis, Oropharyngeal pain, Pyrexia
SMQs:, Torsade de pointes/QT prolongation (broad), Cardiac failure (narrow), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Vestibular disorders (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Cetirizine
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient presented 5/16/2021 with 1 week dizziness, fever and sore throat, found to have acute myopericarditis c/b cardiogenic shock and bradycardic arrest.


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