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This is VAERS ID 1107054

History of Changes from the VAERS Wayback Machine

First Appeared on 6/25/2021

VAERS ID: 1107054
VAERS Form:2
Age:86.0
Sex:Male
Location:Foreign
Vaccinated:2021-02-25
Onset:2021-02-25
Submitted:0000-00-00
Entered:2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ6790-66008 / 1 RA / OT

Administered by: Other      Purchased by: ??
Symptoms: Arthralgia, Body temperature, Coma, Dyspnoea, Loss of consciousness, Malaise, Prothrombin time, Pulmonary oedema, Pyrexia, Rales, Coma scale

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-26
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: AMIODARONE; COUMADIN; BISOPROLOL FUMARATE; TRITTICO; OLANZAPINE; TAVOR [LORAZEPAM]; ENAPREN
Current Illness: Anxiety depression; Arterial hypotension
Preexisting Conditions: Medical History/Concurrent Conditions: Agitated depression; Anxiety neurosis; Aortic valve replacement; Atrial flutter; Hypertension arterial; Tachycardia; Thromboangiitis obliterans
Allergies:
Diagnostic Lab Data: Test Date: 20210225; Test Name: body temperature; Result Unstructured Data: Test Result:37.2 Centigrade; Comments: in the evening; Test Date: 20210226; Test Name: glasgow; Result Unstructured Data: Test Result:3; Test Date: 20201126; Test Name: Pro-thrombin time; Result Unstructured Data: Test Result:results unknown; Test Date: 20210128; Test Name: Pro-thrombin time; Result Unstructured Data: Test Result:results unknown
CDC 'Split Type': ITPFIZER INC2021250927

Write-up: unconsciousness; Dyspnea/dyspnoicity; comatose Glasgow 3; Edema lung; coarse rales; mild pyrexia 37.2 C; general malaise not well; arthralgia; This is a spontaneous report downloaded from The Regulatory Authority-WEB IT-MINISAL02-689131. A contactable physician reported that an 86-year-old male patient received the first dose of bnt162b2 (COMIRNATY, lot number: EJ6790-66008), intramuscular in the right arm on 25Feb2021 12:00 at 0.3 mL, single for COVID-19 immunisation. The patient''s medical history included ongoing anxiety depression, ongoing arterial hypotension, thromboangiitis obliterans, aortic valve replacement, tachycardia, atrial flutter, agitated depression, anxiety neurosis, and hypertension arterial. Concomitant medications included amiodarone (tablet) from 16Oct2014 for tachycardia, warfarin sodium (COUMADIN, tablet) for aortic valve replacement, bisoprolol fumarate (tablet) from 19Jun2012 for atrial flutter, trazodone hydrochloride (TRITTICO, 60 mg/ml oral drops, solution) from 10Feb2020 for anxiety depression, olanzapine from 10Oct2020 to 30Nov2020 for agitated depression, lorazepam (TAVOR, tablet) from 10Apr2015 for anxiety neurosis, and enalapril maleate (ENAPREN, 20 mg tablet) from 15Jun2018 for hypertension arterial. The patient previously took influenza vaccine on Dec2020 for immunization. On 25Feb2021, in the evening, the patient showed a state of general malaise not well defined with arthralgia and mild pyrexia 37.2 Centigrade. On the morning of 26Feb2021 (also reported as 25Feb2021, pending clarification), the patient was found by his wife in a state of unconsciousness and dyspnea/dyspnoicity. Upon the reporter''s arrival at 8:00, the patient was in a comatose Glasgow 3 and edema lung with coarse rales and orotracheal died. The patient underwent other lab tests and procedures which included prothrombin time on 26Nov2020 and on 28Jan2021 with unknown results. The patient died on 26Feb2021. It was not reported if an autopsy was performed. The events were reported as serious with seriousness criteria of death from HA. Sender comment: batch and expiration Sol. Physiological not available; vaccine reconstitution time 11.30; Reporter comment: The clinical worsening occurred at night and the wife did not notice her husband''s condition, so it is difficult to establish the exact dynamics of the facts.; Reported Cause(s) of Death: mild pyrexia 37.2 C; general malaise not well; arthralgia; Edema lung; Dyspnea/dyspnoicity; coarse rales; comatose Glasgow 3; unconsciousness

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