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VAERS Report 2157072

Case Report Section

Vaer Report Details

Age: 41 years old

Gender: Male

State: Outside US

Patient Died?
No
Vaccine information

Name: COVID19 (COVID19 (MODERNA))

Type: Coronavirus 2019 vaccine

Manufacturer: MODERNA

Lot: unknown


Date report was received
2022-03-04
Date form completed
Date Vaccinated
2022-01-09
Date of Onset
17
Number of days (onset date – vaccination date)
17
Adverse Event Description

pulmonary embolism; this case was received (reference number: gr-greof-202200751) on 25-feb-2022 and was forwarded to moderna on 25-feb-2022. this regulatory authority case was reported by a physician and describes the occurrence of pulmonary embolism (pulmonary embolism) in a 41-year-old male patient who received mrna-1273 (spikevax) for covid-19 vaccination. the patient's past medical history included smoker (10 p/y). concomitant products included levothyroxine sodium (thyrohormone) for an unknown indication. on 09-jan-2022, the patient received third dose of mrna-1273 (spikevax) (unknown route) 1 dosage form. on 26-jan-2022, the patient experienced pulmonary embolism (pulmonary embolism) (seriousness criteria hospitalization, medically significant and life threatening). at the time of the report, pulmonary embolism (pulmonary embolism) was resolving. for mrna-1273 (spikevax) (unknown), the reporter did not provide any causality assessments. additional information on concomitant product was reported as thyrohormone levothyroxine sodium. treatment details was not reported by the reporter. company comment: this regulatory case concerns a 41-year-old, male patient with no relevant medical history, who experienced the unexpected, serious (seriousness criteria life-threatening, hospitalization and medically significant), aesi of pulmonary embolism 17 days after the third dose of mrna-1273. at the time of report, outcome of the event was resolving. the benefit-risk relationship of mrna-1273 vaccine is not affected by this report. the case was assessed as serious as per regulatory authority report.; sender's comments: this regulatory case concerns a 41-year-old, male patient with no relevant medical history, who experienced the unexpected, serious (seriousness criteria life-threatening, hospitalization and medically significant), aesi of pulmonary embolism 17 days after the third dose of mrna-1273. at the time of report, outcome of the event was resolving. the benefit-risk relationship of mrna-1273 vaccine is not affected by this report. the case was assessed as serious as per regulatory authority report

Lab Data
na
List of symptoms
pulmonary embolism
Patient Died?
No
Date Died
NA
Birth defect
false
Vaccine Administered By:
Unknown
Vaccine Purchased By:
Unknown
Patient visit ER?
No
Patient Hospitalized?
Yes
Stay in hospital
No
Days in hospital
Unspecified
Permanent disability?
No
Allergies:
na
Current Illness
na