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

This is VAERS ID 1348163

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Case Details

VAERS ID: 1348163 (history)  
Form: Version 2.0  
Age: 54.0  
Sex: Female  
Location: Foreign  
Submitted: 0000-00-00
Entered: 2021-05-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 300042721 / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Circulatory collapse, Fatigue, Headache, Monoplegia, Pyrexia, Somnolence, Vertigo
SMQs:, Anaphylactic reaction (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (narrow), Hypovolaemic shock conditions (narrow), Toxic-septic shock conditions (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypoglycaemic and neurogenic shock conditions (narrow), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Vestibular disorders (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-15
   Days after onset: 44
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lasilacton 20/100 mg; Kalioral; Pantoloc 40 mg; Folsan 5 mg; Hepamerz; Buronil 50 mg
Current Illness: Alcoholic steatohepatitis; Ascites; Depression; Disorder sleep; Gastritis (Gastritis); Hepatic encephalopathy (hepat.); Hypercholesteraemia; Hypertension arterial; Hypokalaemia; Lumbago (Lumbago)
Preexisting Conditions: Medical History/Concurrent Conditions: Bariatric surgery
Diagnostic Lab Data:

Write-up: massive; This regulatory authority case was reported by a physician and describes the occurrence of CIRCULATORY COLLAPSE, the first episode of MONOPLEGIA and the second episode of MONOPLEGIA in a 54-year-old female patient who received mRNA-1273 (COVID 19 Vaccine Moderna) (batch nos. 3001531 and 300042721) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. The patient''s past medical history included Depression since an unknown date, Gastritis (Gastritis) since an unknown date, Hepatic encephalopathy (hepat.) since an unknown date, Bariatric surgery, Ascites since an unknown date, Lumbago (Lumbago) since an unknown date, Disorder sleep since an unknown date, Hypertension arterial since an unknown date, Alcoholic steatohepatitis since an unknown date, Hypokalaemia since an unknown date and Hypercholesteraemia since an unknown date. Concomitant products included Lasilacton 20/100 mg for Ascites, Pantoloc 40 mg for Bariatric surgery and Gastritis, Buronil 50 mg for Disorder sleep, Kalioral for Hypokalaemia, Folsan 5 mg and Hepamerz for an unknown indication. On 16-Mar-2021, the patient received first dose of mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) 1 dosage form. On 13-Apr-2021, received second dose of mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) dosage was changed to 1 dosage form. In March 2021, the patient experienced the first episode of MONOPLEGIA (seriousness criterion medically significant), the second episode of MONOPLEGIA (seriousness criterion medically significant), SOMNOLENCE, the first episode of VERTIGO, HEADACHE, FATIGUE and the first episode of PYREXIA. On 15-Apr-2021, the patient experienced the second episode of VERTIGO and the second episode of PYREXIA. 15-Apr-2021, the patient experienced HEADACHE (massive) and FATIGUE. On 15-Apr-2021 at 7:00 PM, the patient experienced CIRCULATORY COLLAPSE (seriousness criteria death and medically significant). The patient died on 15-Apr-2021. The cause of death was not reported. It is unknown if an autopsy was performed. At the time of death, last episode of MONOPLEGIA, SOMNOLENCE, HEADACHE and FATIGUE had resolved and last episode of VERTIGO, HEADACHE (massive), FATIGUE and the last episode of PYREXIA had not resolved. For mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular), the reporter considered CIRCULATORY COLLAPSE, MONOPLEGIA, MONOPLEGIA, SOMNOLENCE, VERTIGO, VERTIGO, HEADACHE, HEADACHE (massive), FATIGUE, FATIGUE, PYREXIA and PYREXIA to be probably related. 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 AT-BASGAGES-2021-25397, AT-BASGAGES-2021-24979 (E2B Linked Report). Most recent FOLLOW-UP information incorporated above includes: On 13-May-2021: Follow-up information received on 13-MAY-2021 contains non-significant information. On 13-May-2021: Translation received on 19-MAY-2021 and does not contain any new information.; 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. AT-BASGAGES-2021-25397: AT-BASGAGES-2021-24979:; Reported Cause(s) of Death: unknown cause of death

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