National Vaccine
Information Center

Your Health. Your Family. Your Choice.
Search Results

This is VAERS ID 1764974

Government Disclaimer on use of this data

History of Changes from the VAERS Wayback Machine

First Appeared on 10/8/2021

VAERS ID: 1764974
VAERS Form:2
Location:New Hampshire
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Pharmacy      Purchased by: ??
Symptoms: Arthralgia, Drowning, Myocardial necrosis, Myocarditis, Pain, Ventricular hypertrophy, Autopsy, Toxicologic test normal, Intracardiac mass, Pathology test, Gene sequencing, Subgaleal haemorrhage, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-06-20
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: Autopsy report 6/21/2021. Pertinent findings include: no external indication of scalp injury, with small subgaleal hemorrhage over the left occiput; normal epidural, subdural, and subarachnoid evaluations; mildly elevated cardiac mass 420 mg; normal pericardial appearance; normal coronary artery origins from the aorta and free of atherosclerosis; increased left ventricular wall thickness (1.8 cm) and normal right ventricular wall thickness (0.3 cm); normal gross appearance of the endocardium, myocardium, and cardiac valves; small foci of myocardial inflammation of the lateral wall of the left ventricle with myocyte necrosis; negative myocyte disarray; negative toxicology; negative SARS-CoV-2 RT-PCR; Ambry Genetics CardioNext analysis of 92 genes associated with inherited cardiomyopathies and arrhythmias negative for pathologic findings, positive for 2 variants of unknown significance.
CDC 'Split Type':

Write-up: He was in his usual state of good health. 5 days after receiving the vaccine, he complained of brief unilateral shoulder pain (unclear to family which shoulder), which the family attributed to a musculoskeletal source. No chest pains, shortness of breath, or palpitations. He was playing with 2 friends at a community pond, swinging from a rope swing, flipping in the air, and landing in the water feet first. He surfaced, laughed, told his friends "Wow, that hurt!", then swam toward shore, underwater as was his usual routine. The friends became worried when he did not re-emerge. His body was retrieved by local authorities more than an hour later.

New Search

Link To This Search Result:

Copyright © 2022 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166