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This is VAERS ID 104253

Case Details

VAERS ID: 104253 (history)  
Form: Version 1.0  
Age: 71.0  
Sex: Male  
Location: Maryland  
Vaccinated:1997-10-28
Onset:1997-10-28
   Days after vaccination:0
Submitted: 1997-11-04
   Days after onset:7
Entered: 1997-11-05
   Days after submission:1
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E20017HC / UNK - / IM
PPV: PNEUMO (PNU-IMUNE) / PFIZER/WYETH 441214 / 1 RA / IM

Administered by: Public       Purchased by: Public
Symptoms: Asthenia, Cyanosis, Dyspnoea, Hypothermia, Oedema peripheral, Pallor
SMQs:, Cardiac failure (broad), Anaphylactic reaction (broad), Angioedema (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Accidents and injuries (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1997-11-04
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: hx ETOH, tobacco use;
Allergies:
Diagnostic Lab Data: refused lab work
CDC Split Type:

Write-up: presented on 4NOV @ 926AM immed care w/ SOB, weakness, cyanotic, pallor, swelling lt arm-lateral forearm to hand;swollen since inj;T96.8;expired 4NOV97 @ home;


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