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From the 1/7/2022 release of VAERS data:

This is VAERS ID 1333071

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Case Details

VAERS ID: 1333071 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-04-02
Onset:2021-04-02
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-05-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Blood pressure measurement, COVID-19 pneumonia, Heart rate, Influenza like illness, Pyrexia, SARS-CoV-2 test
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-04-21
   Days after onset: 19
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Arterial hypertension (for 30 years); Benign prostatic hyperplasia; Ischemic heart disease (for 30 years); Large intestine carcinoma; Parkinson''s syndrome; Type II diabetes mellitus (for 30 years)
Preexisting Conditions: Medical History/Concurrent Conditions: Cholecystectomy; Skin malignant melanoma excision (on the back)
Allergies:
Diagnostic Lab Data: Test Date: 20210413; Test Name: COVID-19 PCR test; Test Result: Positive ; Result Unstructured Data: Positive; Test Date: 202104; Test Name: Blood pressure; Result Unstructured Data: normal; Test Date: 202104; Test Name: Heart rate; Result Unstructured Data: normal
CDC Split Type: CZMODERNATX, INC.MOD20211

Write-up: This regulatory authority case was reported by a physician and describes the occurrence of COVID-19 PNEUMONIA (oboustrann? covid-19 pneumonie) in a 96-year-old male patient who received mRNA-1273 (COVID 19 Vaccine Moderna) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. The patient''s past medical history included Skin malignant melanoma excision (on the back) and Cholecystectomy. Concurrent medical conditions included Parkinson''s syndrome, Benign prostatic hyperplasia, Large intestine carcinoma since 2019, Arterial hypertension (for 30 years), Type II diabetes mellitus (for 30 years) and Ischemic heart disease (for 30 years). On 02-Apr-2021, the patient received first dose of mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) 1 dosage form. On 02-Apr-2021, after starting mRNA-1273 (COVID 19 Vaccine Moderna), the patient experienced INFLUENZA LIKE ILLNESS. On 15-Apr-2021, the patient experienced COVID-19 PNEUMONIA (seriousness criteria death, hospitalization, medically significant and life threatening). On an unknown date, the patient experienced PYREXIA. The patient died on 21-Apr-2021. The reported cause of death was COVID-19 pneumonia. An autopsy was not performed. At the time of death, INFLUENZA LIKE ILLNESS and PYREXIA outcome was unknown. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On 13-Apr-2021, SARS-CoV-2 test: positive Positive. In April 2021, Blood pressure measurement: normal normal. In April 2021, Heart rate: normal normal. For mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular), the reporter did not provide any causality assessments. The action taken with mRNA-1273 in response to the event was not applicable. Treatment for the events were not provided. No Concomitant medications were provided Company comment: The event of COVID 19 PNEUMONIA is assessed as unlikely related to mRNA-1273 while based on the current available information and temporal association between the use of the product and the start date of the other events, a causal relationship cannot be excluded. This case was linked to CZ-CZSUKL-21004569 (E2B Linked Report).; Sender''s Comments: The event of COVID 19 PNEUMONIA is assessed as unlikely related to mRNA-1273 while based on the current available information and temporal association between the use of the product and the start date of the other events, a causal relationship cannot be excluded. CZ-CZSUKL-21004569:; Reported Cause(s) of Death: COVID-19 pneumonia


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