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From the 1/14/2022 release of VAERS data:

This is VAERS ID 1971636

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Case Details

VAERS ID: 1971636 (history)  
Form: Version 2.0  
Age: 14.0  
Sex: Female  
Location: Foreign  
Vaccinated:2021-09-24
Onset:2021-10-09
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-12-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Brain herniation, Brain injury, Cardiac arrest, Dizziness, Headache, Multiple organ dysfunction syndrome, Nausea, Pyrexia
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Vestibular disorders (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Sepsis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
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:
Allergies:
Diagnostic Lab Data:
CDC Split Type: AUMODERNATX, INC.MOD20214

Write-up: Brain injury; nausea; Cardiac arrest; Brain herniation; Multiple organ dysfunction syndrome; Dizziness; Headache; Pyrexia; This case was received via an unknown source (no reference has been entered for a health authority or license partner) on 14-Dec-2021 and was forwarded to Moderna on 14-Dec-2021. This regulatory authority case was reported by an other health care professional and describes the occurrence of CARDIAC ARREST (Cardiac arrest), BRAIN INJURY (Brain injury), BRAIN HERNIATION (Brain herniation) and MULTIPLE ORGAN DYSFUNCTION SYNDROME (Multiple organ dysfunction syndrome) in a 14-year-old female patient who received mRNA-1273 (Spikevax) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. No Medical History information was reported. On 24-Sep-2021, the patient received first dose of mRNA-1273 (Spikevax) (Intramuscular) 1 dosage form. On 09-Oct-2021, the patient experienced DIZZINESS (Dizziness), HEADACHE (Headache) and PYREXIA (Pyrexia). On 10-Oct-2021, the patient experienced CARDIAC ARREST (Cardiac arrest) (seriousness criteria death and medically significant), BRAIN INJURY (Brain injury) (seriousness criteria death, hospitalization and medically significant), BRAIN HERNIATION (Brain herniation) (seriousness criteria death and medically significant) and MULTIPLE ORGAN DYSFUNCTION SYNDROME (Multiple organ dysfunction syndrome) (seriousness criteria death and medically significant). On an unknown date, the patient experienced NAUSEA (nausea). The patient died on an unknown date. The reported cause of death was Brain herniation, Brain injury, Cardiac arrest and Multiple organ dysfunction syndrome. It is unknown if an autopsy was performed. At the time of death, DIZZINESS (Dizziness) had resolved and NAUSEA (nausea), HEADACHE (Headache) and PYREXIA (Pyrexia) outcome was unknown. The action taken with mRNA-1273 (Spikevax) (Intramuscular) was unknown. For mRNA-1273 (Spikevax) (Intramuscular), the reporter did not provide any causality assessments. On the 10th of October Patient complained to her father that she felt unwell and dizzy. CPR was performed and Patient was transported via ambulance to hospital where Patient was declared deceased. Treatment notes: 16 days post vaccine patient complained of headache and nausea prior to bed; the following morning she was found unconscious at 10:00. RoSC achieved after two shocks; LMA inserted and transported to Hospital; loss of output en route however RoSC achieved after adrenaline and CPR; at hospital. Lab Data: lactate 20 and pH <6.8; in resuscitation, patient had recurrent episodes of loss of cardiac output (non-shockable rhythm) followed by CPR and return of spontaneous circulation; CT brain performed and showed changes in keeping with global ischaemia; subsequently transferred to ICU, where patient sustained rapid development of multiorgan failure as well as hypoxic brain injury with tonsillar herniation; patient passed away morning of 11/10 This is a regulatory case concerning a 14-year-old female patient with no relevant medical history, who experienced the serious unexpected fatal AESI event of Cardiac arrest, serious unexpected fatal events of Brain injury, Brain herniation, Multiple organ dysfunction syndrome and non-serious expected events of Dizziness, Headache, Pyrexia and Nausea. The events occurred approximately 16-17 days after the first dose of mRNA-1273 vaccine administration. The events were considered as related to the product administration. The rechallenge was not applicable. The benefit-risk relationship of mRNA-1273 vaccine is not affected by this report.; Sender''s Comments: This is a regulatory case concerning a 14-year-old female patient with no relevant medical history, who experienced the serious unexpected fatal AESI event of Cardiac arrest, serious unexpected fatal events of Brain injury, Brain herniation, Multiple organ dysfunction syndrome and non-serious expected events of Dizziness, Headache, Pyrexia and Nausea. The events occurred approximately 16-17 days after the first dose of mRNA-1273 vaccine administration. The events were considered as related to the product administration. The rechallenge was not applicable. The benefit-risk relationship of mRNA-1273 vaccine is not affected by this report.; Reported Cause(s) of Death: Brain herniation; Brain injury; Cardiac arrest; Multiple organ dysfunction syndrome


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