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From the 1/29/2021 release of VAERS data (an older release, current is 10/8/2021):

This is VAERS ID 964795



Case Details

VAERS ID: 964795 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-01-13
Onset:2021-01-14
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Blood culture negative, Computerised tomogram head normal, Diarrhoea, Mental status changes, Pyrexia, White blood cell count normal
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Pseudomembranous colitis (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Noninfectious diarrhoea (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Acetaminophen, Aspirin, Axitinib (Inlyta), Bisacodyl, Duloxetine, Ferrous Sulfate, Glucosamine Chondroitin, Norco, Tresiba, Lovastatin, Magnesium, Senna, Tamsulosin, Warfarin
Current Illness: Metastatic Renal Cell Carcinoma Diagnosed with COVID-19 on 12/7/2020, unknown severity of disease. Received first Pfizer SARS-COV-2 vaccine at the end of December
Preexisting Conditions: Insulin dependent Type 2 Diabetes, CKD3, atrial fibrillation, sick sinus syndrome s/p pacemaker on warfarin, hypertension, diastolic heart failure, gastric ulcers, emphysema
Allergies: Penicillin- Swelling of tongue and neck
Diagnostic Lab Data: 1/14/21 CT head unremarkable, blood culture no growth. Normal WBC 1/18/21 blood cultures no growth
CDC Split Type:

Write-up: Symptoms of fever (Tmax 102.9), diarrhea, and altered mental status started ~ 24 hours after vaccination. No evidence of septicemia with negative blood cultures Minimal improvement over 3 days, transferred to tertiary care center for MRI brain after which LP was recommended. However family declined as intubation would have been required and was not consistent with patient''s goals of care.


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https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210129&IDNUMBER=964795

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