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

This is VAERS ID 1152831



Case Details

VAERS ID: 1152831 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Foreign  
Vaccinated:2020-12-31
Onset:2021-01-19
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-03-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Clot retraction, Confusional state, Constipation, Dehydration, Infection, Investigation, Limb discomfort, Peripheral swelling, SARS-CoV-2 test, Urinary tract infection
SMQs:, Cardiac failure (broad), Angioedema (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Extravasation events (injections, infusions and implants) (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Hypoglycaemia (broad), Dehydration (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Blood pressure; Dementia
Allergies:
Diagnostic Lab Data: Test Name: Lab tests; Result Unstructured Data: Test Result:Unknown results; Test Name: COVID-19 virus test; Result Unstructured Data: Test Result:No - Negative COVID-19 test
CDC Split Type: GBPFIZER INC2021306665

Write-up: Poorly dehydrated; Constipated; Urine infection; Became more confused; left leg became very swollen and heavy; left leg became very swollen and heavy; infection; Clot retraction; This is a spontaneous report from a contactable consumer (patient child). This is a report received from the Agency Regulatory Authority. The regulatory authority report number is GB-MHRA-WEBCOVID-202103190919451600, Safety Report Unique Identifier is GB-MHRA-ADR 24975124. An 84-year-old female patient received bnt162b2 (Pfizer-BioNTech COVID-19 Vaccine, Batch/Lot number: Unknown), via an unspecified route of administration on 31Dec2020 as a single dose for COVID-19 immunization. Medical history included dementia and blood pressure. Patient has not had symptoms associated with COVID-19 and is not enrolled in clinical trial. The patient''s concomitant medications were not reported. On an unspecified date the patient was poorly dehydrated, constipated, urine infection, became more confused, left leg became very swollen and heavy and infection. On 19Jan2021, the patient experienced clot retraction (until 20Jan2021, as reported). The patient was taken to A&E of a hospital where the tests were performed (Unknown results). The clinical course was reported as follows: The patient had the vaccine and after that became very poorly dehydrated, constipated and more serious a urine infection she became more confused as she had been suffering from dementia then suddenly left leg became very swollen and heavy. Ambulance was called and patient was diagnosed as having a blood clot and infection and she was dehydrated. On an unspecified date, the patient had COVID-19 virus test and the result was No - Negative COVID-19 test. The case is serious, events causing hospitalization; event clot retraction is fatal. Patient has not tested positive for COVID-19 since having the vaccine. The cause of death was clot retraction. The outcome for events poorly dehydrated, constipated, urine infection, became more confused, left leg became very swollen and heavy and infection was unknown; clot retraction was fatal. An autopsy was not performed. No follow-up attempts are possible. No further information is expected. Information about lot/batch number cannot be obtained.; Reported Cause(s) of Death: Clot retraction


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