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

This is VAERS ID 1153022



Case Details

VAERS ID: 1153022 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Foreign  
Vaccinated:2021-01-01
Onset:2021-01-01
   Days after vaccination:0
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: Blood pressure measurement, Hypotension, Infection, Pneumonia, SARS-CoV-2 test, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (broad), 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? No
Hospitalized? No
Previous Vaccinations:
Other Medications: MOXALOLE; EBIXA; CYKLOKAPRON; PARACETAMOL NET; RISPERIDON ACTAVIS; OXASCAND; MIRTAZAPIN ACTAVIS
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Anxiety; Dementia; Depressed mood; Pain; Renal failure
Allergies:
Diagnostic Lab Data: Test Date: 202101; Test Name: blood pressure; Result Unstructured Data: Test Result:95/47 mmHg; Test Date: 202101; Test Name: COVID-19 virus test; Test Result: Negative
CDC Split Type: SEPFIZER INC2021282922

Write-up: Fainted; Blood pressure 95/47; Suspected infection/pneumonia; Suspected infection/pneumonia; This is a spontaneous report from a contactable physician downloaded from the Agency Regulatory Authority-WEB (Regulatory Authority report number: SE-MPA-2021-007688). A 95-year-old male patient received BNT162B2 (COMIRNATY, Lot number and expiration date were not reported) in Jan2021 as a single dose, with route of administration unspecified, for COVID-19 immunization. Medical history included pain, dementia, anxiety, depressed mood and renal failure; all unknown if ongoing. Concomitant medications included macrogol 3350, potassium chloride, sodium bicarbonate, sodium chloride (MOXALOLE) from 19Nov2020 to an unspecified date; memantine hydrochloride (EBIXA) from Jan2021 to an unspecified date; tranexamic acid (CYKLOKAPRON) from 19Nov2020 to an unspecified date; paracetamol (PARACETAMOL NET) from 19Nov2020 to an unspecified date; risperidone (RISPERIDON ACTAVIS) from 19Nov2020 to an unspecified date; oxazepam (OXASCAND) from 05Nov2020 to an unspecified date; and mirtazapine (MIRTAZAPIN ACTAVIS) from 19Nov2020 to an unspecified date. In Jan2021, 22 days after the vaccination, the patient had fainted while sitting on a chair; and blood pressure was at 95/47 mmHg. The events were reported to be serious (medically significant). The patient''s COVID-19 virus test in Jan2021 came back negative. A few days later, on an unspecified date in 2021, the patient had died, and the cause of death was suspected infection/pneumonia according to the death certificate. No autopsy was performed. The outcome of the events, ''fainted'' and ''blood pressure was at 95/47 mmHg'', was unknown. No follow-up attempts are possible. No further information is expected. Information on lot and batch numbers cannot be obtained.; Reported Cause(s) of Death: Suspected infection/pneumonia; Suspected infection/pneumonia


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