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From the 1/14/2022 release of VAERS data:

This is VAERS ID 1011983

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Case Details

VAERS ID: 1011983 (history)  
Form: Version 1.0  
Age: 77.0  
Sex: Male  
Location: Florida  
   Days after vaccination:35
Submitted: 2021-01-27
   Days after onset:1
Entered: 2021-02-05
   Days after submission:9
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: Other
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, Atrial fibrillation, Bacterial test positive, Bilirubin conjugated, Blood albumin, Blood bilirubin, Blood creatinine increased, Blood culture negative, Blood urea nitrogen/creatinine ratio, Bronchoscopy abnormal, Chest X-ray abnormal, Chest tube insertion, Condition aggravated, Culture urine negative, Cystatin C increased, Death, Dyspnoea, General physical health deterioration, Hepatic enzyme increased, Hypoxia, Intensive care, Ischaemic hepatitis, Klebsiella infection, Lung infiltration, Pneumonia, Protein total, Respiratory failure, SARS-CoV-2 test negative, Serratia infection, Spinal cord injury, Stenotrophomonas infection, Tachycardia, Tracheal aspirate culture
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Liver related investigations, signs and symptoms (narrow), Hepatitis, non-infectious (narrow), Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Supraventricular tachyarrhythmias (narrow), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (broad), Opportunistic infections (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   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: Other Medication acetaminophen, albuterol/ipratropium, amlodipine, ascorbic acid, atorvastatin, baclofen, buspirone, calcium carbonate with vitamin D, cholecalciferol, dexmedetomidine, diltiazem, docusate, esomeprazole, famotidine, fentanyl
Current Illness:
Preexisting Conditions:
Diagnostic Lab Data: Collection DT Spec CoV19BF COVIDIg 01/21/2021 14:10 NASAL Not Detected 01/12/2021 04:00 SERUM 0.03 01/11/2021 12:35 NASAL Not Detected Collection DT Spec WBC BUN Creat Cystn-C 01/25/2021 04:00 BLOOD 15.28 H 01/25/2021 04:00 PLASM 64 H 1.3 2.46 H 01/24/2021 04:00 PLASM 56 H 1.1 01/24/2021 04:00 BLOOD 13.16 H 01/23/2021 04:40 BLOOD 14.02 H 01/23/2021 04:00 PLASM 52 H 0.9 01/23/2021 04:00 BLOOD 7.93 01/22/2021 04:00 BLOOD 10:58 H 01/22/2021 04:00 PLASM 49 H 0.9 01/21/2021 04:00 PLASM 47 H 1.0 01/21/2021 04:00 BLOOD 7.39 01/20/2021 04:00 PLASM 30 H 0.8 01/20/2021 04:00 BLOOD 9.10 01/19/2021 04:00 PLASM 17 0.7 L Collection DT Spec Protein Albumi TotBili DirBili AST AlkPhos 01/25/2021 04:00 PLASM 5.6 L 3.2 L 1.1 1096 H 504 H 51 01/24/2021 04:00 PLASM 6.0 L 3.2 L 0.8 1482 H 699 H 57 01/23/2021 04:00 PLASM 5.5 L 2.9 L 0.6 1778 H 1044 H 53 01/22/2021 04:00 PLASM 5.7 L 2.6 L 0.4 2135 H 1579 H 49 01/21/2021 17:00 PLEUR 1.3 01/14/2021 04:00 PLASM 6.8 3.2 L 0.4 15 21 57 01/13/2021 04:00 PLASM 6.3 L 3.0 L 0.3 14 18 53 01/12/2021 04:00 PLASM 5.8 L 2.7 L 0.3 11 17 55
CDC Split Type:

Write-up: Narrative: See "Other Relevant History" in Section 6 above Other Relevant Hx: 76yo man with a history of for C5 tetraplegia 2/2 cervical stenosis leading to neurogenic bowel/bladder (chronic suprapubic catheter) and chronic respiratory failure with tracheostomy, severe dysphagia s/p G tube placement and multiple aspiration pneumonias, COPD GOLD III, hx MRSA bacteremia (7/2018) and E coli bacteremia (12/2019). Patient transferred from Spinal Cord Injury until to ICU on 1/11/2021 due to worsneing dyspnea, hypoxia (80s) and tachycardia and was found to have acute hypoxic respiratory failure likely 2/2 multifocal pneumonia. CXR findings of "There is interval increase in patchy airspace infiltrates and consolidation in bilateral lungs concerning for pneumonia" Patient was started on vancomycin and pip/tazo on 1/11 and tracheal aspirate cultures were obtained for VAP diagnosis which ultimately grew Serratia liquifaciens and Proteus mirabilis. Infectious Diseases was consulted who recommended a switch to ertapenem therapy for a total 10 day course for VAP. UCx/BCx remained negative. On 1/20, a therapeutic bronchoscopy was completed with cultures growing Stenotrophomonas maltophilia and pan-S Klebsiella pneumoniae. The following day a chest tube was inserted and the course of ertapenem completed but vancomycin was continued. By 1/22, patient developed shock liver with ALT/AST 2135/1579 from normal range the day prior and SCr increased to 1.3 from baseline 0.7/cystatin C of 2.46 up from 1.15. Levofloxacin was added for Stenotrophomonas coverage. By 1/25, patient''s clinical status continued to decline and Cardiology was consulted for new onset Afib with RVR. Discussion was documented with patient''s family who requested DNR. Patient passed away in the early AM on 1/26. Demise does not appear to be related to COVID-19 vaccination but occurred in recent timeframe. Symptoms: ElevatedLiverEnzymes & death, pneumonia, afib

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