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From the 5/14/2021 release of VAERS data (an older release, current is 9/17/2021):

This is VAERS ID 1112122



Case Details

VAERS ID: 1112122 (history)  
Form: Version 2.0  
Age: 43.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-13
Onset:2021-03-15
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805029 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Aggression, Mood altered, Pulmonary embolism, Pulseless electrical activity, Respiratory arrest, Sudden death
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), Dementia (broad), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Hostility/aggression (narrow), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Depression (excl suicide and self injury) (broad), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-15
   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: Macrobid 100 mg po BID Cefepime 2g daily (3/12-3/19) Dilaudid 2 mg po PRN pain gabapentin 600 mg BID Methotrexate qFriday Metoprolol 25 mg BID Odefsey (HAART) Mirtazipine daily Glipizide, insulin for DM2
Current Illness: Complicated lower UTI (hospitalized for this- received vaccine in house) - MDR bacteria
Preexisting Conditions: Neurosarcoidosis Transverse myelitis with lower paraplegia HIV positive (on HAART) DM2 MDD
Allergies: PCN Cipro Ertapenem Fosfomycin
Diagnostic Lab Data: None. Patient was being discharged. I suspected a massive PE however pt was on DVT prophylaxis. The coroner refused to do an autopsy so cause of death was not known but it was a highly unusual and unexpected outcome.
CDC Split Type:

Write-up: Patient was admitted for Multi drug resistant UTI (for which he has been admitted many times before). Was hospitalized for 3 days while awaiting cultures, hemodynamically stable, with no lab abnormalities. On the day of discharge (sensitivities to UTI came back, pt to be discharged on cefepime, had PICC line) pt got up from bed, sat on the edge of the bed and was being given belongings by the nurse, alert and oriented and in a pleasant mood, when suddenly pt grabbed at his chest and stated "I can''t breathe" and became combative and altered when O2 was attempted to be placed on pt''s face; then pt had PEA arrest x3 and unable to achieve ROSC.


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https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210514&IDNUMBER=1112122


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