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This is VAERS ID 103878

Case Details

VAERS ID: 103878 (history)  
Form: Version 1.0  
Age: 57.0  
Sex: Male  
Location: Unknown  
Vaccinated:1997-09-11
Onset:1997-09-22
   Days after vaccination:11
Submitted: 1997-10-09
   Days after onset:17
Entered: 1997-10-28
   Days after submission:19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUSHIELD) / PFIZER/WYETH 4978168 / UNK LA / IM

Administered by: Unknown       Purchased by: Unknown
Symptoms: Guillain-Barre syndrome, Neuropathy, Pneumonia, Respiratory disorder
SMQs:, Peripheral neuropathy (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (narrow), Demyelination (narrow), Eosinophilic pneumonia (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Immune-mediated/autoimmune disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1997-10-07
   Days after onset: 15
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 15 days
   Extended hospital stay? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness:
Preexisting Conditions: allergies PCN;LBBB;
Allergies:
Diagnostic Lab Data: neuro consult suggested;polyneuropathy D/T GBS
CDC Split Type:

Write-up: pt recv vax 11SEP97 & came in 22SEP97 w/GBS expired 7OCT97 d/t ARDS secondary to pneumonia secondary to GBS;polyneuropathy d/t GBS;


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