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From the 10/15/2021 release of VAERS data:

This is VAERS ID 1076017



Case Details

VAERS ID: 1076017 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-04
Onset:2021-03-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Agonal respiration, Alanine aminotransferase increased, Anion gap increased, Aspartate aminotransferase increased, Bilirubin conjugated increased, Blood albumin decreased, Blood alkaline phosphatase increased, Blood bicarbonate decreased, Blood bilirubin increased, Blood calcium decreased, Blood chloride normal, Blood creatine phosphokinase increased, Blood creatinine increased, Blood glucose decreased, Blood magnesium normal, Blood pH decreased, Blood potassium increased, Blood sodium normal, Blood urea increased, Carbon dioxide decreased, Death, Glomerular filtration rate decreased, Hypotension, Lipase increased, Multiple organ dysfunction syndrome, Protein total decreased, Syncope, Troponin I increased
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Liver related investigations, signs and symptoms (narrow), Anaphylactic reaction (broad), Acute pancreatitis (broad), Lactic acidosis (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Biliary system related investigations, signs and symptoms (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Tumour lysis syndrome (narrow), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (narrow), Dehydration (broad), Hypokalaemia (broad), Sepsis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-05
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: elderly diabetic man with AFib/RVR who presented with multiorgan failure few hours after receiving his 2nd COVID shot today and ultimately expired. he did well after the 1st COVID shot and subsequently developed this multiorgan failure after the 2nd shot. had his second COVID vaccine shot around 4 pm, went home and collapsed, lay on the floor for a few hours refusing to call paramedics, eventually wife called 911, he arrived to ED and was dead a few hours later. -on arrival the pH was 6.7, agonal breathing, low BP, lactate 18, but no MI, no stroke, no apparent infection/sepsis. important to note that he had a covid vaccine just a few hours from collapsing and dying.
Allergies:
Diagnostic Lab Data: Troponin I 0.00 - 0.05 ng/mL 0.07 result = .07 CK=Results as of 3/5/2021 13:19 3/5/2021 00:05 Creatine Kinase (CK): 1,379 (H) Results as of 3/5/2021 13:19 3/5/2021 00:05 Sodium: 142 Potassium: 5.1 Chloride: 104 CO2 (Bicarbonate): 8 (LL) Anion Gap: 35.1 (H) Urea Nitrogen (BUN): 25 Creatinine: 2.67 (H) GFR Est-Other: 21 (L) GFR Est-African American: 24 (L) Calcium: 8.9 Total Protein: 5.8 (L) Albumin: 2.7 (L) Bilirubin Total: 1.4 (H) Bilirubin Direct: 1.0 (H) Alkaline Phosphatase: 142 (H) AST: 3,288 (H) ALT: 960 (H) Lipase: 2,074 (H) Magnesium: 2.1 CO2 (Bicarbonate) 21 - 32 = mmol/L 8 Anion Gap 6 - 16 mmol/L 35.1High Comment: The Anion Gap calculation uses the following formula: (Na+K)-(Cl+CO2)=anion gap. There are other means of calculating anion gap that may yield a different value. Therefore, the clinical history of the patient should be considered when interpreting the anion gap value. Glucose 70 - 100 mg/dL 56Low BUN 6 - 25 mg/dL 25 Creatinine 0.50 - 1.30 mg/dL 2.67High Comment: IDMS-traceable method GFR Est-Other $g60 See Cmnt 21Low GFR Est-African American $g60 See Cmnt 24Low Comment: Units: mL/min/1.73 m2. Estimated glomerular filtration rate values are calculated using the CKD-EPI equation Contains abnormal data LIVER PANEL (HEPATIC) Order: 1323606024 Status: Final result Ref Range & Units 3/5/21 0005 Total Protein 6.4 - 8.2 g/dL 5.8Low Albumin 3.2 - 4.7 g/dL 2.7Low Total Bilirubin <1.1 mg/dL 1.4High Direct Bilirubin 0.0 - 0.30 mg/dL 1.0High Alkaline Phosphatase 26 - 137 U/L 142High AST 0 - 37 U/L 3,288High Comment: Results verified by dilution ALT 12 - 78 U/L 960High
CDC Split Type:

Write-up: elderly diabetic man with AFib/RVR who presented with multiorgan failure few hours after receiving his 2nd COVID shot today and ultimately expired. he did well after the 1st COVID shot and subsequently developed this multiorgan failure after the 2nd shot. had his second COVID vaccine shot around 4 pm, went home and collapsed, lay on the floor for a few hours refusing to call paramedics, eventually wife called 911, he arrived to ED and was dead a few hours later. -on arrival the pH was 6.7, agonal breathing, low BP, lactate 18, but no MI, no stroke, no apparent infection/sepsis. important to note that he had a covid vaccine just a few hours from collapsing and dying.


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