VAERS ID: 2139356

AGE: 13| SEX: F|STATE: FR (Unknown)

Description

Acute Myocarditis; This is a spontaneous report received from a contactable reporter(s) (Consumer or other non HCP). The reporter is the parent. A 13 year-old female patient (not pregnant) received bnt162b2 (BNT162B2), administered in arm left, administration date 29Nov2021 (Lot number: FJ8760) at the age of 13 years as dose 1, single for covid-19 immunisation. The patient's relevant medical history and concomitant medications were not reported. The patient did not receive any other vaccines within 4 weeks prior to the COVID vaccine. No any other medications the patient received within 2 weeks of vaccination. The following information was reported: MYOCARDITIS (death) with onset 05Dec2021, outcome "fatal", described as "Acute Myocarditis". The patient date of death was 05Dec2021. The reported cause of death was myocarditis. The autopsy revealed "adverse reaction to pfizer vaccine" (adverse event following immunisation). Prior to vaccination, the patient was not diagnosed with COVID-19. Since the vaccination, the patient has not been tested for COVID-19. No follow-up attempts are possible. No further information is expected.; Reported Cause(s) of Death: Myocarditis; Autopsy-determined Cause(s) of Death: Adverse reaction to pfizer vaccine

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Symptoms

Myocarditis

Vaccines

VAX DATE: 11-29-2021| ONSET DATE: 12-05-2021| DAYS TO ONSET: 6
NameDose #TypeManufacturerLotRouteSite
COVID19 (COVID19 (PFIZER-BIONTECH)) 1 COVID19 PFIZER\BIONTECH FJ8760 LA

RECVDATE:02-25-2022
RPT_DATE:
CAGE_YR:
CAGE_MO:
DIED:Y
DATEDIED:12-05-2021
L_THREAT:U
ER_VISIT:
HOSPITAL:U
HOSPDAYS:
X_STAY:U
DISABLE:U
RECOVD:N
LAB_DATA:
V_ADMINBY:OTH
OTHER_MEDS:
CUR_ILL:
HISTORY:
PRIOR_VAX:
SPLTTYPE:PHPFIZER INC202200298777
FORM_VERS:
TODAYS_DATE:02-23-2022
BIRTH_DEFECT:U
OFC_VISIT:U
ER_ED_VISIT:U
ALLERGIES:
V_FUNDBY:

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