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From the 9/17/2021 release of VAERS data:

This is VAERS ID 1633205

Case Details

VAERS ID: 1633205 (history)  
Form: Version 2.0  
Age: 13.0  
Sex: Male  
Location: Foreign  
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-08-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: Activated partial thromboplastin time, Disseminated intravascular coagulation, International normalised ratio, Multiple organ dysfunction syndrome, N-terminal prohormone brain natriuretic peptide, Platelet count, Prothrombin time, Pulmonary haemorrhage, Pyrexia, Septic shock, Troponin T
SMQs:, Haemorrhage terms (excl laboratory terms) (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 (narrow), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-08-14
   Days after onset: 1
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:
Preexisting Conditions: Medical History/Concurrent Conditions: Dysphagia; Extremely preterm (less than 28 weeks); Hypoxic-ischaemic encephalopathy; Posthaemorrhagic hydrocephalus; Reflux oesophagitis; Respiratory insufficiency; Symptomatic epilepsy
Diagnostic Lab Data: Test Name: pTT; Result Unstructured Data: Test Result:$g180 seconds; Test Name: INR; Result Unstructured Data: Test Result:4.9; Test Name: proBNP; Result Unstructured Data: Test Result:24937 pg/mL; Test Name: Platelets; Result Unstructured Data: Test Result:min 3410x31uml; Test Name: Quick; Result Unstructured Data: Test Result:<10; Test Name: Troponin T; Result Unstructured Data: Test Result:1580 pg/mL
CDC Split Type: DEPFIZER INC202101072828

Write-up: Disseminated intravascular coagulation; Lung hemorrhage; Pyrexia; Multiorgan failure; Septic shock; This is a spontaneous report from a non-contactable other HCP. DE-PEI-202100168078. A 13-yars-old male patient received bnt162b2 (COMIRNATY, Formulation: Solution for Injection, Batch/Lot Number: 10020A) dose 2 0.3 mL via an unknown route of administration on 11Aug2021 (at the age of 13-years-old) as dose 1, single for COVID-19 immunisation. The patient''s medical history included extremely preterm (less than 28 weeks), Hypoxic-ischaemic encephalopathy, posthaemorrhagic hydrocephalus, symptomatic epilepsy, dysphagia, respiratory insufficiency, reflux oesophagitis on an unspecified date. The patient previously received first dose of bnt162b2 (COMIRNATY, Formulation: Solution for Injection) dose 1, Batch/Lot number unknown) for COVID-19 immunisation on 16Jun2021. Concomitant medications were not reported. The patient underwent lab tests and procedures which included platelets min 3410x 31uml, Quick <10, INR$g4.9, pTT $g180 sec, proBNP 24937 pg/ml, Trop T 1580 pg/ml on an unknown date. The patient experienced multiorgan failure, lung hemorrhage, disseminated intravascular coagulation, pyrexia and septic shock on 13Aug2021. The patient died due to Unknown cause of death on 14Aug2021. Seriousness for the events was reported as death, hospitallization and life threatening. The autopsy details were not reported. Sender Comment: Platelets min 3410^31uml, Quick <10, INR$g4,9; pTT $g180 sec, proBNP 24937 pg/ml, Trop T 1580 pg/ml Relatedness of drug to reaction(s)/event (s) Result of Assessment D. Unclassifiable No follow-up attempts possible. No further information expected.; Reported Cause(s) of Death: Unknown cause of death

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