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From the 10/8/2021 release of VAERS data:

This is VAERS ID 1014897



Case Details

VAERS ID: 1014897 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Foreign  
Vaccinated:2021-01-14
Onset:2021-01-01
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH UNK / UNK - / OT

Administered by: Other       Purchased by: ?
Symptoms: Computerised tomogram thorax, Cyanosis, Death, General physical health deterioration, Pneumonia, Respiratory failure, Syncope, Urinary tract infection
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (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), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   Days after onset: 20
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Arterial hypertension; Arterial stent insertion (Stent-PTA of the popliteal artery and the right tibiofibular trunk in 2011); Atrial fibrillation (Permanent atrial fibrillation - NOAC with Pradaxa); Cholecystolithiasis; Chronic gastritis; Chronic renal insufficiency (stage II); Depressive disorder; Hepatomegaly; Hyperlipidaemia; Hypertensive heart disease; Hyperuricemia; Liver fatty (Grade II); Peripheral arterial occlusive disease Fontaine stage I; Triple vessel disease; Type 2 diabetes mellitus
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Test Date: 20210121; Test Name: CT chest; Result Unstructured Data: Test Result:pronounced pneumonia
CDC Split Type: DEPFIZER INC2021103905

Write-up: Respiratory failure; Syncope; Pneumonia; Cyanosis; General physical condition decreased; Unknown cause of death; urinary tract infection; This is a spontaneous report from a non-contactable consumer downloaded from the Medicines Agency (MA) Regulatory Authority-WEB [DE-PEI-CADRPEI-2021013072]. An 85-year-old male patient received the first dose of bnt162b2 (COMIRNATY), intramuscularly on 14Jan2021 at single dose for prophylactic vaccination. Medical history included Peripheral arterial occlusive disease Fontaine stage I, Arterial stent insertion (Stent-PTA of the popliteal artery and the right tibiofibular trunk in 2011), Atrial fibrillation (Permanent atrial fibrillation - NOAC with Pradaxa), Triple vessel disease, Type 2 diabetes mellitus, Arterial hypertension, Hypertensive heart disease, Chronic renal insufficiency stage II, Hyperlipidaemia, Chronic gastritis, Cholecystolithiasis, Grade II Liver fatty, Hepatomegaly, Depressive disorder, Hyperuricemia, all were ongoing. The patient''s concomitant medications were not reported. 8 days after vaccination (as reported), on 21Jan2021 the patient developed Respiratory failure and Syncope and Cyanosis and General physical condition decreased and Pneumonia, lasting for unknown. Patient in the PFH syncopated and fallen out of bed, dyspnoic, resp. partial insufficiency, with oxygen requirement -$g hospital admission -$g oxygen demand 8l/min, antibiotics for urinary tract infection, pronounced pneumonia in the CT chest. The patient was dead on 21Jan2021. The patient had not recovered from the events Respiratory failure and Syncope and Cyanosis and General physical condition decreased and Pneumonia at the date of reporting, and outcome of urinary tract infection was unknown. Death cause was reported as Unknown cause of death. It was not reported if an autopsy was performed. Senders comment: Peripheral arterial occlusive disease stage I; Stent-PTA of the popliteal artery and the right tibiofibular trunk in 2011; Permanent atrial fibrillation - NOAC with Pradaxa; Three vessel coronary disease; Type 2 diabetes mellitus; Arterial hypertension with hypertensive heart disease; Chronic renal insufficiency St. II; Hyperlipidemia; Chronic gastritis; Cholecystolithiasis; Grade II fatty liver with hepatomegaly; Depressive disorder; Hyperuricemia. Patient in the PFH syncopated and fallen out of bed, dyspnoic, resp. partial insufficiency. with oxygen requirement -$g hospital admission -$g oxygen demand 8l/min, antibiotics for urinary tract infection, pronounced pneumonia in the CT chest, both, anamnestic vaccination COVID 19 on 14Jan2021. Information on the lot/batch number has been requested.; Reported Cause(s) of Death: Unknown cause of death


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