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This is VAERS ID 105125

Case Details

VAERS ID: 105125 (history)  
Form: Version 1.0  
Age: 100.0  
Sex: Female  
Location: New York  
Vaccinated:1997-10-27
Onset:1997-10-27
   Days after vaccination:0
Submitted: 1997-11-17
   Days after onset:21
Entered: 1997-11-25
   Days after submission:8
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 7F81916 / 1 - / IM

Administered by: Unknown       Purchased by: Unknown
Symptoms: Chills, Dyspnoea, Pallor, Productive cough, Pyrexia, Tremor
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Parkinson-like events (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalopathy/delirium (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1997-10-30
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: NONE
Preexisting Conditions: no allergies-had degenerative osteoarthritis cerebrovascular insufficiency
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt recv vax 27OCT97 & w/in a few hr T103.3, chills, shaking, inc temp cont for 2 days on 29OCT:T106.3 color pale blowing resp exp green sputum transferred to hosp;


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