VAERS ID: 2109613

AGE: 20| SEX: M|STATE: CT (United States)

Description

Started to have joint pains in elbows around 6/14/2021. Patient started to wear elbow braces. Started to have joint pains in shoulders around 6/21/2021. Patient bought and used shoulder brace. Started to have joint pains in left knee around 7/12/2021. Patient bought and used knee brace. Started to have Joint pains in right knee around 8/18/2021. Patient bought and used knee brace. September 4, 2021 - Went to his primary care Doctor, for joint pains September 5, 2021 - Went to Hospital ER for worsening pains and right foot swollen. September 9, 2021 - Went back to Hospital ER for worsening swelling and left foot swollen - pain got worse. September 17, 2021 - Rushed Hospital ER. He was having hard time breathing and coughing up blood. Hospital rushed him to another Hospital. They found that he was suffering from ANCA Vasculitis and Good Pasture Vasculitis. September 18, 2021 - He was put in an induced coma and placed on a ventilator. October 28, 2021 - He passed away from the damage caused by the Vasculitis.

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Symptoms

Arthralgia, Dyspnoea, Haemoptysis, Death, Mechanical ventilation, Orthosis user, Medical induction of coma, Anti-neutrophil cytoplasmic antibody positive vasculitis, Peripheral swelling, Goodpasture's syndrome

Vaccines

VAX DATE: 05-13-2021| ONSET DATE: 06-26-2021| DAYS TO ONSET: 44
NameDose #TypeManufacturerLotRouteSite
COVID19 (COVID19 (MODERNA)) 0 COVID19 MODERNA 014C21A SYR LA

RECVDATE:02-13-2022
RPT_DATE:
CAGE_YR:20
CAGE_MO:
DIED:Y
DATEDIED:10-28-2021
L_THREAT:Y
ER_VISIT:
HOSPITAL:Y
HOSPDAYS:42
X_STAY:U
DISABLE:U
RECOVD:N
LAB_DATA:
V_ADMINBY:PVT
OTHER_MEDS:NONE
CUR_ILL:NONE
HISTORY:NONE
PRIOR_VAX:
SPLTTYPE:
FORM_VERS:
TODAYS_DATE:02-12-2022
BIRTH_DEFECT:U
OFC_VISIT:Y
ER_ED_VISIT:Y
ALLERGIES:NONE
V_FUNDBY:

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