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

This is VAERS ID 1107095

Case Details

VAERS ID: 1107095 (history)  
Form: Version 2.0  
Sex: Female  
Location: Foreign  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: Death, General physical health deterioration, Livedo reticularis, Pyrexia, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Asthma; Chronic obstructive pulmonary disease; Vascular dementia
Diagnostic Lab Data:
CDC Split Type: SEPFIZER INC2021256608

Write-up: Death; uncontactable; impaired general condition; fever; mottled on the legs; This is a spontaneous report from a contactable nurse downloaded from the regulatory authority-WEB (Regulatory authority numbers SE-MPA-2021-009261 and SE-MPA-1614601604152). An 83-year-old female patient received BNT162B2 (COMIRNATY, lot number EJ6797) intramuscular, in Feb2021, at 0.3 ml single, for COVID-19 immunisation. Medical history included chronic obstructive pulmonary disease, vascular dementia and asthma, all from an unknown date and unknown if ongoing. The patient had 24 unspecified concomitant medications. The patient was vaccinated and rapidly deteriorated two days later with impaired general condition, fever, was uncontactable and became mottled on the legs. The patient died three days after Comirnaty was given, on an unspecified date in Feb2021. Report assessed as serious (fatal) for death. The other events outcome was unknown. It was unknown if an autopsy was done. No follow-up attempts are possible. No further information expected.; Reported Cause(s) of Death: Death

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