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This is VAERS ID 1034116

History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1034116
VAERS Form:2
Age:58.0
Sex:Female
Location:Virginia
Vaccinated:2021-01-19
Onset:2021-01-30
Submitted:0000-00-00
Entered:2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 UN / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Biopsy skin abnormal, Blister, Dermatitis, Rash, Skin exfoliation, Toxic epidermal necrolysis, Epidermal necrosis

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-15
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Escitalopram 10mg tablet Novolin 70/30 Insulin Diazepam 2mg tablet Simvastatin 20mg tablet Acetaminophen 500mg tablet
Current Illness: Diabetes - Type 2 Dementia CVA s/p L-sided weakness Psychiatric disorder
Preexisting Conditions:
Allergies: Buspirone Morphine
Diagnostic Lab Data: Surgical Pathology reports: FINAL DIAGNOSIS: SKIN, RIGHT THIGH, BIOPSY: SUBEPIDERMAL BULLAE WITH EXTENSIVE EPIDERMAL NECROSIS AND MIXED INFLAMMATORY INFILTRATE. NO EVIDENCE OF MALIGNANCY. Comment: The clinical concern for toxic epidermal necrolysis is noted, and the histologic findings support this impression. Extensive subepidermal bullous formation with associated mixed inflammatory infiltrate composed of neutrophils, eosinophils, and lymphocytes is noted in the larger of the two skin fragments, while the smaller fragment shows diffuse epidermal necrosis, which is compatible with TEN.
CDC 'Split Type':

Write-up: Presented from clinic with 3-4 days of extensive rash. There were multiple areas of skin sloughing on bilateral upper extremities and abdominal wall.


Changed on 5/7/2021

VAERS ID: 1034116 Before After
VAERS Form:2
Age:58.0
Sex:Female
Location:Virginia
Vaccinated:2021-01-19
Onset:2021-01-30
Submitted:0000-00-00
Entered:2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 UN / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Biopsy skin abnormal, Blister, Dermatitis, Rash, Skin exfoliation, Toxic epidermal necrolysis, Epidermal necrosis

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-15
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Escitalopram 10mg tablet Novolin 70/30 Insulin Diazepam 2mg tablet Simvastatin 20mg tablet Acetaminophen 500mg tablet
Current Illness: Diabetes - Type 2 Dementia CVA s/p L-sided weakness Psychiatric disorder
Preexisting Conditions:
Allergies: Buspirone Morphine Morphine
Diagnostic Lab Data: Surgical Pathology reports: FINAL DIAGNOSIS: SKIN, RIGHT THIGH, BIOPSY: SUBEPIDERMAL BULLAE WITH EXTENSIVE EPIDERMAL NECROSIS AND MIXED INFLAMMATORY INFILTRATE. NO EVIDENCE OF MALIGNANCY. Comment: The clinical concern for toxic epidermal necrolysis is noted, and the histologic findings support this impression. Extensive subepidermal bullous formation with associated mixed inflammatory infiltrate composed of neutrophils, eosinophils, and lymphocytes is noted in the larger of the two skin fragments, while the smaller fragment shows diffuse epidermal necrosis, which is compatible with TEN.
CDC 'Split Type':

Write-up: Presented from clinic with 3-4 days of extensive rash. There were multiple areas of skin sloughing on bilateral upper extremities and abdominal wall.


Changed on 5/14/2021

VAERS ID: 1034116 Before After
VAERS Form:2
Age:58.0
Sex:Female
Location:Virginia
Vaccinated:2021-01-19
Onset:2021-01-30
Submitted:0000-00-00
Entered:2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 UN / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Biopsy skin abnormal, Blister, Dermatitis, Rash, Skin exfoliation, Toxic epidermal necrolysis, Epidermal necrosis

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-15
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Escitalopram 10mg tablet Novolin 70/30 Insulin Diazepam 2mg tablet Simvastatin 20mg tablet Acetaminophen 500mg tablet
Current Illness: Diabetes - Type 2 Dementia CVA s/p L-sided weakness Psychiatric disorder
Preexisting Conditions:
Allergies: Buspirone Morphine Morphine
Diagnostic Lab Data: Surgical Pathology reports: FINAL DIAGNOSIS: SKIN, RIGHT THIGH, BIOPSY: SUBEPIDERMAL BULLAE WITH EXTENSIVE EPIDERMAL NECROSIS AND MIXED INFLAMMATORY INFILTRATE. NO EVIDENCE OF MALIGNANCY. Comment: The clinical concern for toxic epidermal necrolysis is noted, and the histologic findings support this impression. Extensive subepidermal bullous formation with associated mixed inflammatory infiltrate composed of neutrophils, eosinophils, and lymphocytes is noted in the larger of the two skin fragments, while the smaller fragment shows diffuse epidermal necrosis, which is compatible with TEN.
CDC 'Split Type':

Write-up: Presented from clinic with 3-4 days of extensive rash. There were multiple areas of skin sloughing on bilateral upper extremities and abdominal wall.

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