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

This is VAERS ID 1064574



Case Details

VAERS ID: 1064574 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Foreign  
Vaccinated:2021-01-28
Onset:2021-02-04
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ6795 / 1 LA / OT

Administered by: Other       Purchased by: ?
Symptoms: Cardio-respiratory arrest
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Respiratory failure (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: AERIUS [EBASTINE]; APIXABAN; ATENOLOL; DIFFU-K; DOLIPRANE; ESOMEPRAZOLE; FUROSEMIDE; LACRIFLUID; ZESTORETIC; LERCAN
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Abdominal aortic aneurysm enlargement; Atrial flutter; Cognitive disturbance; Coxarthrosis; Dyslipidaemia; Fibrillation atrial; Heart failure; Hip prosthesis user; Hypertension arterial; Hypoacusis; Seafood allergy
Allergies:
Diagnostic Lab Data:
CDC Split Type: FRPFIZER INC2021180562

Write-up: Cardio-respiratory arrest; This is a spontaneous report from a contactable Other Health Professional (HCP) downloaded from the regulatory authority-WEB FR-AFSSAPS-AN20210344. This is a report received from the Regulatory Authority. A 91-year-old female patient received first dose of bnt162b2 (COMIRNATY, lot number: EJ6795), via intramuscular on left arm on 28Jan2021 at single dose for COVID-19 vaccination. Medical history included cognitive disturbance, hypertension arterial, heart failure, atrial flutter, hip prosthesis user, hypoacusis, seafood allergy, dyslipidaemia, abdominal aortic aneurysm enlargement, coxarthrosis, fibrillation atrial, all from unspecified dates and unknown if ongoing. Concomitant medication included ebastine (AERIUS), apixaban, atenolol, potassium chloride (DIFFU-K), paracetamol (DOLIPRANE), esomeprazole, furosemide, carbomer (LACRIFLUID), hydrochlorothiazide, lisinopril (ZESTORETIC), lercanidipine hydrochloride (LERCAN). The patient experienced cardio-respiratory arrest on 04Feb2021. The event was reported as serious due to death and life-threatening. Case narrative: The first injection of Comirnaty carried out on 28Jan2021. On 04Feb2021, the patient presented with cardio-respiratory arrest leading to her death. Death from cardiopulmonary arrest 7 days after the first injection of Comirnaty. The patient died on 04Feb2021. It was not reported if an autopsy was performed. The outcome of the event was fatal. No medical observation available for this patient according to the declarant. No follow-up attempts possible. No further information expected. Follow-up (23Feb2021): New information received from the same contactable Other Health Professional (HCP) downloaded from the regulatory authority FR-AFSSAPS-AN20210344 includes: No medical observation available for this patient according to the declarant. No follow-up attempts possible. No further information expected.; Reported Cause(s) of Death: Cardio-respiratory arrest


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