VAERS ID: 1813648

AGE: 12| SEX: F|STATE: LA (United States)

Description

Patient vaccinated 8/28/2021. Developed COVID symptoms on 9/20/2021, with positive Antigen test. Symptoms of MIS began on 9/23/2021. Admitted to ICU for 5 day treatment. Discharged on 9/28/2021.

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Symptoms

Malaise, Laboratory test, Intensive care, COVID-19, SARS-CoV-2 test positive, Multisystem inflammatory syndrome

Vaccines

VAX DATE: 08-28-2021| ONSET DATE: 09-23-2021| DAYS TO ONSET: 26
NameDose #TypeManufacturerLotRouteSite
COVID19 (COVID19 (PFIZER-BIONTECH)) 1 COVID19 PFIZER\BIONTECH FC3184 IM LA

RECVDATE:10-24-2021
RPT_DATE:
CAGE_YR:12
CAGE_MO:
DIED:U
DATEDIED:
L_THREAT:U
ER_VISIT:
HOSPITAL:Y
HOSPDAYS:5
X_STAY:U
DISABLE:U
RECOVD:Y
LAB_DATA:Extensive
V_ADMINBY:PHM
OTHER_MEDS:
CUR_ILL:
HISTORY:Asthma
PRIOR_VAX:
SPLTTYPE:
FORM_VERS:
TODAYS_DATE:10-23-2021
BIRTH_DEFECT:U
OFC_VISIT:U
ER_ED_VISIT:U
ALLERGIES:
V_FUNDBY:

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