VAERS ID: 2013695

AGE: 20| SEX: M|STATE: FR (Unknown)

Description

PALLOR; HEADACHE; DIZZINESS; SEIZURE; This regulatory authority case was reported by an other health care professional and describes the occurrence of PALLOR (PALLOR), HEADACHE (HEADACHE), DIZZINESS (DIZZINESS) and SEIZURE (SEIZURE) in a 20-year-old male patient who received mRNA-1273 (COVID-19 Vaccine Moderna) (batch nos. 007H21A and 010G21B) for an unknown indication. No Medical History information was reported. On 03-Nov-2021, the patient received first dose of mRNA-1273 (COVID-19 Vaccine Moderna) (Intramuscular) 1 dosage form. On 02-Dec-2021, received second dose of mRNA-1273 (COVID-19 Vaccine Moderna) (Intramuscular) dosage was changed to 1 dosage form. On 02-Dec-2021, the patient experienced PALLOR (PALLOR) (seriousness criterion death), HEADACHE (HEADACHE) (seriousness criterion death), DIZZINESS (DIZZINESS) (seriousness criterion death) and SEIZURE (SEIZURE) (seriousness criterion death). The patient died on 02-Dec-2021. The reported cause of death was Pallor, Headache, Dizziness and Seizure. It is unknown if an autopsy was performed. Not Provided For mRNA-1273 (COVID-19 Vaccine Moderna) (Intramuscular), the reporter did not provide any causality assessments. No Concomitant medications were provided. Treatment information was not provided DOA 06:10PM at Company comment: This regulatory authority case concerns a 20-year-old male patient, with no reported medical history, who experienced the fatal events of PALLOR, HEADACHE, DIZZINESS and SEIZURE. The events occurred on the same day after receiving a second dose of mRNA-1273 and patient died on that same day. No further information was provided for medical reviewing. It is stated on the narrative that patient was dead on arrival. It is unknown if an autopsy was performed. The benefit-risk relationship of mRNA-1273 is not affected by this report. Event terms and seriousness criterion was captured as provided by the Regulatory Authority.; Sender's Comments: This regulatory authority case concerns a 20-year-old male patient, with no reported medical history, who experienced the fatal events of PALLOR, HEADACHE, DIZZINESS and SEIZURE. The events occurred on the same day after receiving a second dose of mRNA-1273 and patient died on that same day. No further information was provided for medical reviewing. It is stated on the narrative that patient was dead on arrival. It is unknown if an autopsy was performed. The benefit-risk relationship of mRNA-1273 is not affected by this report. Event terms and seriousness criterion was captured as provided by the Regulatory Authority.; Reported Cause(s) of Death: PALLOR; HEADACHE; DIZZINESS; SEIZURE

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Symptoms

Dizziness, Headache, Pallor, Seizure

Vaccines

VAX DATE: 11-03-2021| ONSET DATE: 12-02-2021| DAYS TO ONSET: 29
NameDose #TypeManufacturerLotRouteSite
COVID19 (COVID19 (MODERNA)) 1 COVID19 MODERNA 010G21B OT

RECVDATE:01-07-2022
RPT_DATE:
CAGE_YR:
CAGE_MO:
DIED:Y
DATEDIED:12-02-2021
L_THREAT:U
ER_VISIT:
HOSPITAL:U
HOSPDAYS:
X_STAY:U
DISABLE:U
RECOVD:N
LAB_DATA:
V_ADMINBY:
OTHER_MEDS:
CUR_ILL:
HISTORY:
PRIOR_VAX:
SPLTTYPE:PHMODERNATX, INC.MOD20214
FORM_VERS:
TODAYS_DATE:01-05-2022
BIRTH_DEFECT:U
OFC_VISIT:U
ER_ED_VISIT:U
ALLERGIES:
V_FUNDBY:

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