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From the 2/12/2021 release of VAERS data:

This is VAERS ID 108923

Case Details

VAERS ID: 108923 (history)  
Form: Version 1.0  
Age: 73.0  
Sex: Female  
Location: Wisconsin  
   Days after vaccination:16
Submitted: 1997-11-12
   Days after onset:21
Entered: 1998-03-26
   Days after submission:134
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Unknown       Purchased by: Unknown
Symptoms: Arthralgia, Asthenia, Chills, Condition aggravated, Constipation, Cough, Diarrhoea, Dizziness, Dyspepsia, Dyspnoea, Fatigue, Feeling cold, Headache, Influenza, Influenza like illness, Myalgia, Nausea, Pyrexia
SMQs:, Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Pseudomembranous colitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific dysfunction (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Vestibular disorders (broad), Arthritis (broad), Noninfectious diarrhoea (narrow), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1997-10-31
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, 10 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Dyazide-water pill
Current Illness: NONE
Preexisting Conditions: HTN, dizziness;
Diagnostic Lab Data: 2wk later on 22OCT97 felt resp diff breathing merthiolate, thimerosal rxn;
CDC Split Type:

Write-up: extreme fatigue, muscles/joint pain, h/a, gastrointestinal upset, constipation, diarrhea, chills-feeling cold, dry cough, fever;22OCT97 exp extreme diff breathing & dizziness;pt felt had the flu;. All these symptoms started on Oct 6, 1997 when the influenza, pneumococcal vaccines were administered. Her health continued to deteriorate and on Oct 22, 1997 in the evening she experienced extreme difficulty breathing and then later dizziness. At this point she was taken to the Emergency room of hospital. Felt nauseated at home- threw up at hospital. Asthenia, headache, diarrhea, no dyspnea, myalgia, dyspepsia, chills fever, flu symd, arthralgia, constipation, cough inc, reaction aggrav.

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