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This is VAERS ID 103878

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 103878
VAERS Form:
Age:57.4
Sex:Male
Location:Unknown
Vaccinated:1997-09-11
Onset:1997-09-22
Submitted:1997-10-09
Entered:1997-10-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: FLUSHIELD 1997-1998 / WYETH 4978168 / - LA / IM

Administered by: Unknown      Purchased by: Unknown
Symptoms: NEUROPATHY, GUILLAIN BARRE SYND, PNEUMONIA, RESPIRAT DIS

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-07
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? Yes, days: 15     Extended hospital stay? No
Previous Vaccinations:
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;


Changed on 12/8/2009

VAERS ID: 103878 Before After
VAERS Form:
Age:57.4
Sex:Male
Location:Unknown
Vaccinated:1997-09-11
Onset:1997-09-22
Submitted:1997-10-09
Entered:1997-10-29 1997-10-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: FLUSHIELD 1997-1998 INFLUENZA (SEASONAL) (FLUSHIELD 97-98) / WYETH WYETH PHARMACEUTICALS, INC 4978168 / - LA / IM

Administered by: Unknown      Purchased by: Unknown
Symptoms: Guillain-Barre syndrome, Neuropathy, Pneumonia, Respiratory disorder, NEUROPATHY, GUILLAIN BARRE SYND, PNEUMONIA, RESPIRAT DIS

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-07
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? Yes, days: 15     Extended hospital stay? No
Previous Vaccinations:
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;


Changed on 8/31/2010

VAERS ID: 103878 Before After
VAERS Form:
Age:57.4
Sex:Male
Location:Unknown
Vaccinated:1997-09-11
Onset:1997-09-22
Submitted:1997-10-09
Entered:1997-10-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUSHIELD 97-98) INFLUENZA (SEASONAL) (FLUSHIELD) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH 4978168 / - LA / IM

Administered by: Unknown      Purchased by: Unknown
Symptoms: Guillain-Barre syndrome, Neuropathy, Pneumonia, Respiratory disorder

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-07
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? Yes, days: 15     Extended hospital stay? No
Previous Vaccinations:
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;


Changed on 7/7/2013

VAERS ID: 103878 Before After
VAERS Form:
Age:57.4
Sex:Male
Location:Unknown
Vaccinated:1997-09-11
Onset:1997-09-22
Submitted:1997-10-09
Entered:1997-10-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUSHIELD) / PFIZER/WYETH 4978168 / - LA / IM
FLU3: INFLUENZA (SEASONAL) (FLUSHIELD) / PFIZER/WYETH 4978168 / - LA / IM

Administered by: Unknown      Purchased by: Unknown
Symptoms: Guillain-Barre syndrome, Neuropathy, Pneumonia, Respiratory disorder

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-07
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? Yes, days: 15     Extended hospital stay? No
Previous Vaccinations:
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;


Changed on 2/14/2017

VAERS ID: 103878 Before After
VAERS Form:
Age:57.4 57.0
Sex:Male
Location:Unknown
Vaccinated:1997-09-11
Onset:1997-09-22
Submitted:1997-10-09
Entered:1997-10-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUSHIELD) / PFIZER/WYETH 4978168 / - LA / IM

Administered by: Unknown      Purchased by: Unknown
Symptoms: Guillain-Barre syndrome, Neuropathy, Pneumonia, Respiratory disorder

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-07
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? Yes, days: 15     Extended hospital stay? No
Previous Vaccinations:
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;


Changed on 5/14/2017

VAERS ID: 103878 Before After
VAERS Form:
Age:57.0
Sex:Male
Location:Unknown
Vaccinated:1997-09-11
Onset:1997-09-22
Submitted:1997-10-09
Entered:1997-10-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUSHIELD) / PFIZER/WYETH 4978168 / - LA / IM

Administered by: Unknown      Purchased by: Unknown
Symptoms: Guillain-Barre syndrome, Neuropathy, Pneumonia, Respiratory disorder

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-07
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? Yes, days: 15     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;


Changed on 9/14/2017

VAERS ID: 103878 Before After
VAERS Form:(blank) 1
Age:57.0
Sex:Male
Location:Unknown
Vaccinated:1997-09-11
Onset:1997-09-22
Submitted:1997-10-09
Entered:1997-10-28
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-07
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? Yes, days: 15     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;


Changed on 2/14/2018

VAERS ID: 103878 Before After
VAERS Form:1
Age:57.0
Sex:Male
Location:Unknown
Vaccinated:1997-09-11
Onset:1997-09-22
Submitted:1997-10-09
Entered:1997-10-28
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-07
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? Yes, days: 15     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;


Changed on 6/14/2018

VAERS ID: 103878 Before After
VAERS Form:1
Age:57.0
Sex:Male
Location:Unknown
Vaccinated:1997-09-11
Onset:1997-09-22
Submitted:1997-10-09
Entered:1997-10-28
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-07
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? Yes, days: 15     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;


Changed on 8/14/2018

VAERS ID: 103878 Before After
VAERS Form:1
Age:57.0
Sex:Male
Location:Unknown
Vaccinated:1997-09-11
Onset:1997-09-22
Submitted:1997-10-09
Entered:1997-10-28
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-07
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? Yes, days: 15     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;


Changed on 9/14/2018

VAERS ID: 103878 Before After
VAERS Form:1
Age:57.0
Sex:Male
Location:Unknown
Vaccinated:1997-09-11
Onset:1997-09-22
Submitted:1997-10-09
Entered:1997-10-28
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-07
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? Yes, days: 15     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;


Changed on 10/14/2018

VAERS ID: 103878 Before After
VAERS Form:1
Age:57.0
Sex:Male
Location:Unknown
Vaccinated:1997-09-11
Onset:1997-09-22
Submitted:1997-10-09
Entered:1997-10-28
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-07
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? Yes, days: 15     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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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=103878&WAYBACKHISTORY=ON


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