| VAERS ID: |
934539 (history) |
| Form: |
Version 2.0 |
| Age: |
68.0 |
| Sex: |
Female |
| Location: |
Kentucky |
| Vaccinated: | 2021-01-08 |
| Onset: | 2021-01-09 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-11 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
D12L20A / 1 |
RA / IM |
Administered by: Public Purchased by: ?
Symptoms: Autopsy,
Blood test,
Culture tissue specimen,
Death,
Toxicologic test,
Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-09
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: Singulair, Oxybutynin, Fosamax, Prednisone, Meloxicam, Eliquis, Bumetanide, Triamcinolone cream, Klor-Con, Lisinopril, Promethazine,
Current Illness: Cellulitis of left lower limb (12/2020)
Preexisting Conditions: Hypertension
Allergies: No known allergies
Diagnostic Lab Data: Postmortem examination was performed at the State Medical Examiner Office on January 10, 2021 (MEC21-0019). Tissue samples were obtained for histology and red top/tiger top/purple top tubes of blood were obtained for potential further studies. Samples of blood and vitreous humor were also obtained and submitted to AXIS Laboratories for toxicologic analysis.
CDC Split Type:
Write-up: Patient received COVID-19 (Moderna) vaccine from the Health Department on afternoon of January 8, 2021 and went to sleep approximately 2300 that night. Was found unresponsive in bed the following morning and pronounced dead at 1336 on January 9, 2021 |
