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From the 4/23/2021 release of VAERS data:

This is VAERS ID 982890



Case Details

VAERS ID: 982890 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Mississippi  
Vaccinated:2021-01-22
Onset:2021-01-25
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Bradycardia, Death, Endotracheal intubation, Pulse absent, Resuscitation, SARS-CoV-2 test positive, Troponin increased, White blood cell count increased
SMQs:, Angioedema (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Crestor 10 mg po daily Norvasc 10 mg po daily benazepril 20 mg po daily Gabapentin 600 mg po daily Toprol XL 100 mg po daily
Current Illness: GI Bleed and Anemia- DX: 1/31/2021
Preexisting Conditions: ASCVD, HTN, Blindness, Diverticulous
Allergies: No Known Drug Allergies
Diagnostic Lab Data: 1/25/2021- Troponin 3.010; WBC 19.6
CDC Split Type:

Write-up: Pt presented to ER via EMS at 1556 3 days after receiving vaccine. pt was breathing approximately 50 times a minutes and o2 sats in the 70''s upon arrival. NP decided to intubate, Rocuronium and Versed given. Pt became bradycardic and 1 amp of Atropine was given without improvement. No pulse felt, CPR started per ACLS protocol. 7 Epi''s given. Time of death- 1632. After TOD pt was swabbed for COVID-19 and the results were positive.


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