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

This is VAERS ID 1165509



Case Details

VAERS ID: 1165509 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-03-04
Onset:2021-03-09
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-04-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ER2659 / 1 - / -

Administered by: Other       Purchased by: ?
Symptoms: Cardiac arrest, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-01
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: COMBODART; PRAVASTATIN; BETMIGA; SALBUTAMOL; BISOPROLOL; RIVAROXABAN; SPIRIVA RESPIMAT; LACTULOSE; ESOMEPRAZOLE; SPIRONOLACTONE; BURINEX; SERETIDE EVOHALER
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Atrial fibrillation; COPD; Heart failure; Hypertension
Allergies:
Diagnostic Lab Data:
CDC Split Type: IEPFIZER INC2021342353

Write-up: COLLAPSE; CARDIAC ARREST; This is a spontaneous report from a contactable physician downloaded from the Agency Regulatory Authority-WEB, regulatory authority number IE-HPRA-2021-068553. An 84-year-old male patient received bnt162b2 (COMIRNATY), dose 1 via an unspecified route of administration on 04Mar2021 (at the age of 84-years-old) (Batch/Lot Number: ER2659) as 0.3 ml single for covid-19 immunisation. Medical history included cardiac failure, chronic obstructive pulmonary disease, hypertension, atrial fibrillation. Concomitant medications included dutasteride, tamsulosin hydrochloride (COMBODART); pravastatin; mirabegron (BETMIGA); salbutamol; bisoprolol; rivaroxaban; tiotropium bromide (SPIRIVA RESPIMAT); lactulose; esomeprazole; spironolactone; bumetanide (BURINEX); fluticasone propionate, salmeterol (SERETIDE EVOHALER); all taken for unspecified indications, start and stop dates were not reported. On 09Mar2021, the patient collapsed at home/also reported as syncope. The patient was brought by ambulance to the Emergency Department (ED). The patient experienced cardiac arrest and standard resuscitation was performed. The reporter outlined that it was unclear if the event was in any way related to vaccine administration, but the reporter was reporting as per protocol. In Mar2021, the patient died. It was not reported if an autopsy was performed. No follow-up attempts possible. No further information expected. Batch/lot number already provided.; Reported Cause(s) of Death: Syncope; Cardiac arrest


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