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This is VAERS ID 107856

Case Details

VAERS ID: 107856 (history)  
Form: Version 1.0  
Age: 79.0  
Sex: Female  
Location: Michigan  
Vaccinated:1997-10-15
Onset:1997-10-16
   Days after vaccination:1
Submitted: 1998-02-21
   Days after onset:128
Entered: 1998-02-27
   Days after submission:6
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 7F81816 / UNK LA / -

Administered by: Private       Purchased by: Unknown
Symptoms: Guillain-Barre syndrome
SMQs:, Peripheral neuropathy (narrow), Guillain-Barre syndrome (narrow), Demyelination (narrow), Immune-mediated/autoimmune disorders (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, 39 days
   Extended hospital stay? Yes
Previous Vaccinations: ~ ()~~~In patient
Other Medications: Insulin (Humulin);Dyazide;Cardizem;Xanax;
Current Illness: NONE
Preexisting Conditions: diabetes, chronic lymphocytic leukemia, HTN
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: dx w/GBS (principal) secondary: adverse effect viral vaccine;


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