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From the 10/8/2021 release of VAERS data:

This is VAERS ID 1056105



Case Details

VAERS ID: 1056105 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Foreign  
Vaccinated:2021-01-28
Onset:2021-01-31
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ6134 / 1 - / OT

Administered by: Other       Purchased by: ?
Symptoms: Asthenia, Blood pressure measurement, Body temperature, Chest X-ray, Electrocardiogram, Fatigue, Feeding disorder, Heart rate, Oxygen saturation, Pyrexia, SARS-CoV-2 test
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: RIPEDON; CHINOTAL; ACETYLSALICYLIC ACID; SERMION [NICERGOLINE]; GERODORM; XANAX
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Cachexia; Dementia; Hypertension; Ischaemic heart disease; Melanoma; Psychiatric disorder NOS
Allergies:
Diagnostic Lab Data: Test Date: 20210201; Test Name: Blood pressure; Result Unstructured Data: Test Result:113/62 mmHg mmHg; Test Date: 20210201; Test Name: Body temperature; Result Unstructured Data: Test Result:38.4 degrees Celsius Centigrade; Test Date: 20210202; Test Name: Chest X-ray; Result Unstructured Data: Test Result:pneumonia right side; Test Date: 20210201; Test Name: EKG; Result Unstructured Data: Test Result:atrial fibrillation,; Comments: atrial fibrillation, HR:152/min, aVF negative T waves, V4-V6 ascending ST depression; Test Date: 20210201; Test Name: Heart rate; Result Unstructured Data: Test Result:152/min; Test Date: 20210201; Test Name: Oxygen saturation; Test Result: 89 %; Test Date: 20210202; Test Name: COVID-19 PCR test; Test Result: Negative ; Test Date: 20210204; Test Name: COVID-19 PCR test; Test Result: Negative ; Test Date: 20210201; Test Name: COVID-19 rapid POC test; Test Result: Negative
CDC Split Type: HUPFIZER INC2021183051

Write-up: could not be fed; weakness; Prostration; fever; This is a spontaneous report from a contactable physician downloaded from the Agency Regulatory Authority-WEB regulatory authorityHU-OGYI-050421. An 83-year-old male patient received first dose of bnt162b2 (COMIRNATY, Lot#: EJ6134), intramuscular on 28Jan2021 19:14 at 0.3 mL, single for covid-19 immunisation. Medical history included dementia from an unknown date and unknown if ongoing , cachexia from an unknown date and unknown if ongoing , ischaemic heart disease from an unknown date and unknown if ongoing , melanoma from an unknown date and unknown if ongoing , psychiatric disorders NOS from an unknown date and unknown if ongoing , hypertension from an unknown date and unknown if ongoing. Concomitant medication included risperidone (RIPEDON) 1 film-coated tablet (twice a day), pentoxifylline (CHINOTAL) (unknown dose, three times a day), unknown acetylsalicylic acid (100 mg once daily), nicergoline (SERMION [NICERGOLINE]) 30 mg film-coated tablet (once daily), cinolazepam (GERODORM) (once daily), alprazolam (XANAX) 0,25 mg tablet (three times a day). The occurence of weakness, prostration and feeding disorder resulting in death after the administration of Comirnaty concentrate for dispersion for injection (30 micrograms of COVID-19 mRNA Vaccine: BioNTech Manufacturing GmbH/ Pfizer). On 28Jan2021 at 19:14, the patient received the first dose of Comirnaty (COVID-19 mRNA Vaccine (nucleoside modified)/ Tozinameran) concentrate for dispersion for injection (strength: 1 dose (0.3 mL) contains 30 micrograms of COVID-19 mRNA Vaccine, intramuscularly, left arm, batch number: EJ 6134) for COVID-19 immunisation. On 31Jan2021, the patient experienced fever, weakness, prostration, and feeding disorder (could not be fed). On 01Feb2021 the patient was taken to the emergency, where EKG, COVID-19 PCR and chest X-ray was performed. X-ray showed right sided pneumonia. He received 1500 ml saline solution due to dehydratation and 1 ampoule Algopyrin (metamizole sodium), unknown Ceftriaxon (intravenously, 2 gr), and Fragmin injection (dalteparin sodium, 2500 NE daily). The patient died on 04Feb2021 at 5:45 am silently. Autopy was done, cause of death was subtotal pulmonary embolism caused by deep vein thrombosis, and poor general condition. Established diagnoses: Atherosclerosis generalized, Ventricular hypertrophy hypertrophia, Pulmonary oedema, Bronchopneumonia, Embolism pulmonary. The reporter physician did not consider the events to be related to vaccination. Tests included On 01Feb2021, EKG: atrial fibrillation, HR:152/min, aVF negative T waves, V4-V6 ascending ST depression, Oxygen saturation: 89 percent, COVID-19 rapid test: negative, Blood pressure: 113/62, Body temperature: 38.4 degrees Celsius. On 02Feb2021, COVID-19 PCR test: negative, Chest X-ray: pneumonia right side. On 04Feb2021, COVID-19 PCR test: negative. Sender Comment: 83-year-old patient died 6 days after vaccination with Comirnaty. Cause of death was pulmonary embolism according to the autopsy. The causal relationship between the events and Comirnaty is considered unlikely. The case is serious due to the fatal outcome. No follow-up attempts are possible. No further information is expected.; Reported Cause(s) of Death: pulmonary embolism


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