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VAERS Report 2157225

Case Report Section

Vaer Report Details

Age: 67 years old

Gender: Male

State: Outside US

Patient Died?
Yes
Vaccine information

Name: COVID19 (COVID19 (MODERNA))

Type: Coronavirus 2019 vaccine

Manufacturer: MODERNA

Lot: 007g21a


Date report was received
2022-03-04
Date form completed
Date Vaccinated
2021-12-20
Date of Onset
40
Number of days (onset date – vaccination date)
40
Adverse Event Description

diarrhea, vomiting, inappetite, extreme weakness, saturday evening. on sunday without eating or getting out of bed. monday morning death from cardiac arrest.; diarrhea, vomiting, inappetite, extreme weakness, saturday evening. on sunday without eating or getting out of bed. monday morning death from cardiac arrest.; diarrhea, vomiting, inappetite, extreme weakness, saturday evening. on sunday without eating or getting out of bed. monday morning death from cardiac arrest.; diarrhea, vomiting, inappetite, extreme weakness, saturday evening. on sunday without eating or getting out of bed. monday morning death from cardiac arrest.; diarrhea, vomiting, inappetite, extreme weakness, saturday evening. on sunday without eating or getting out of bed. monday morning death from cardiac arrest.; this case was received via agency (reference number: it-minisal02-840904) on 24-feb-2022 and was forwarded to moderna on 24-feb-2022. this regulatory authority case was reported by a consumer and describes the occurrence of cardiac arrest (diarrhea, vomiting, inappetite, extreme weakness, saturday evening. on sunday without eating or getting out of bed. monday morning death from cardiac arrest.), decreased appetite (diarrhea, vomiting, inappetite, extreme weakness, saturday evening. on sunday without eating or getting out of bed. monday morning death from cardiac arrest.), vomiting (diarrhea, vomiting, inappetite, extreme weakness, saturday evening. on sunday without eating or getting out of bed. monday morning death from cardiac arrest.), diarrhoea (diarrhea, vomiting, inappetite, extreme weakness, saturday evening. on sunday without eating or getting out of bed. monday morning death from cardiac arrest.) and asthenia (diarrhea, vomiting, inappetite, extreme weakness, saturday evening. on sunday without eating or getting out of bed. monday morning death from cardiac arrest.) in a 67-year-old male patient who received mrna-1273 (spikevax) (batch no. 007g21a) for covid-19 vaccination. healthy patient with mild hypertension. on 20-dec-2021, the patient received dose of mrna-1273 (spikevax) (intramuscular) .5 milliliter. on 29-jan-2022, the patient experienced cardiac arrest (diarrhea, vomiting, inappetite, extreme weakness, saturday evening. on sunday without eating or getting out of bed. monday morning death from cardiac arrest.) (seriousness criterion death), decreased appetite (diarrhea, vomiting, inappetite, extreme weakness, saturday evening. on sunday without eating or getting out of bed. monday morning death from cardiac arrest.) (seriousness criterion death), vomiting (diarrhea, vomiting, inappetite, extreme weakness, saturday evening. on sunday without eating or getting out of bed. monday morning death from cardiac arrest.) (seriousness criterion death), diarrhoea (diarrhea, vomiting, inappetite, extreme weakness, saturday evening. on sunday without eating or getting out of bed. monday morning death from cardiac arrest.) (seriousness criterion death) and asthenia (diarrhea, vomiting, inappetite, extreme weakness, saturday evening. on sunday without eating or getting out of bed. monday morning death from cardiac arrest.) (seriousness criterion death). it is unknown if an autopsy was performed. no concomitant medications were mentioned. no treatment details were reported. company comment: this regulatory authority case concerns a 67-year-old male patient with relevant medical history of mild hypertension, who experienced serious, fatal unexpected events of cardiac arrest, vomiting, diarrhoea, asthenia, decreased appetite, that occurred approximately 40 days after the dose of the mrna-1273. reportedly, the patient had diarrhea, vomiting, inappetence, extreme weakness on saturday evening. on sunday, the patient did not eat and could not get out of the bed. on monday morning, the patient passed away due to cardiac arrest. the patient's relevant medical history is a possible confounder for cardiac arrest. the benefit-risk relationship of mrna-1273 is not affected by this report. the events reported and seriousness assessment retained as per regulatory authority reporting. healthy patient with mild hypertension; reporter's comments: adrs received on 03/02/22: it was not possible to ask the signaller to modify profile. vaccine sum at 15.39; 1 lot dose 21c1003 sum on date 12/05/21 h 8.17. summed zone not available.; sender's comments: this regulatory authority case concerns a 67-year-old male patient with relevant medical history of mild hypertension, who experienced serious, fatal unexpected events of cardiac arrest, vomiting, diarrhoea, asthenia, decreased appetite, that occurred approximately 40 days after the dose of the mrna-1273. reportedly, the patient had diarrhea, vomiting, inappetence, extreme weakness on saturday evening. on sunday, the patient did not eat and could not get out of the bed. on monday morning, the patient passed away due to cardiac arrest. the patient's relevant medical history is a possible confounder for cardiac arrest. the benefit-risk relationship of mrna-1273 is not affected by this report. the events reported and seriousness assessment retained as per regulatory authority reporting

Lab Data
na
List of symptoms
diarrhoea vomiting cardiac arrest decreased appetite asthenia
Patient Died?
Yes
Date Died
NA
Birth defect
false
Vaccine Administered By:
Unknown
Vaccine Purchased By:
Unknown
Patient visit ER?
No
Patient Hospitalized?
No
Stay in hospital
No
Days in hospital
Unspecified
Permanent disability?
No
Allergies:
na
Current Illness
na