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

This is VAERS ID 1104996



Case Details

VAERS ID: 1104996 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Foreign  
Vaccinated:2021-01-29
Onset:2021-02-07
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / OT

Administered by: Other       Purchased by: ?
Symptoms: Blood culture, Body temperature, Chronic obstructive pulmonary disease, Dyspnoea, Erysipelas, Pyrexia, Scan, Sepsis
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Test Date: 20210208; Test Name: blood culture; Result Unstructured Data: Test Result:Blood cultures positive for Pseudomonas aeruginos; Comments: Blood cultures positive for Pseudomonas aeruginosa. Death 08Feb2021 in a context of sepsis.; Test Date: 20210208; Test Name: Body temperature; Result Unstructured Data: Test Result:40 Centigrade; Test Date: 20210207; Test Name: scanner; Result Unstructured Data: Test Result:Normal
CDC Split Type: FRPFIZER INC2021233068

Write-up: Fever at 40 degree C; Breath shortness; Chronic obstructive pulmonary disease; erysipelas; sepsis; This is a spontaneous report from a contactable physician downloaded from the regulatory authority-WEB, regulatory authority number FR-AFSSAPS-MP20210291. An 83-year-old male patient received first dose of BNT162B2 (COMIRNATY, Solution for injection, lot/batch number not provided), intramuscular on 29Jan2021 (at unspecified age) at single dose for COVID-19 immunisation. The patient medical history and concomitant medications were not reported. No History of COVID-19. Patient considered to be at risk of developing a severe form of COVID-19 disease. Patient vaccinated as part of the COVID-19 vaccination campaign. Patient was hospitalized on unknown date for decompensation of COPD (Chronic obstructive pulmonary disease) and erysipelas, both events occurred on 07Feb2021 and were treated with Augmentin (amoxicillin/clavulanic acid) on a probabilistic basis. Patient was hospitalized on unknown date for Breath shortness (07Feb2021). Death 08Feb2021 in a context of sepsis (08Feb2021). Patient was hospitalized on unknown date for Fever at 40 degree C (08Feb2021). The patient underwent lab tests and procedures which included 07Feb2021: Normal scanner. 08Feb2021: Fever at 40 degree C motivating the carrying out of blood cultures in front of a probable sepsis in the context of erysipelas. 08Feb2021: Blood cultures positive for Pseudomonas aeruginosa. Death 08Feb2021 in a context of sepsis (08Feb2021). The patient died on 08Feb2021. It was unknown if an autopsy was performed. The outcome of the event sepsis was fatal, for other events was not recovered. No follow-up attempts are possible; information about lot/batch number cannot be obtained.; Reported Cause(s) of Death: sepsis


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