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From the 11/19/2021 release of VAERS data:

This is VAERS ID 1298123

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Case Details

VAERS ID: 1298123 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Foreign  
Vaccinated:2021-04-01
Onset:2021-04-14
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-05-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / OT

Administered by: Other       Purchased by: ?
Symptoms: Cardiac arrest, Death, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-14
   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: QUEPIN
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Chronic obstructive pulmonary disease (STARTED 4 DECADES AGO); Dementia
Allergies:
Diagnostic Lab Data:
CDC Split Type: GRPFIZER INC2021491367

Write-up: Death; Vomiting; Cardiac arrest; This is a spontaneous report from a contactable consumer downloaded from the regulatory authority-WEB (GR-GREOF-20212525). An 81-year-old female patient received the first dose of BNT162B2 (COMIRNATY), intramuscularly, on 01Apr2021 as a single dose for COVID-19 immunisation. Medical history included chronic obstructive pulmonary disease (started 4 decades ago) and dementia from 2019. Prior to the vaccination, the patient was not diagnosed with COVID-19. Concomitant medications included quetiapine fumarate (QUEPIN) from 09Sep2020 to 13Apr2021. The patient previously received the influenza vaccination (MANUFACTURER UNKNOWN) for immunisation in Nov2020. The patient experienced death, vomiting, and cardiac arrest on 14Apr2021, reported as medically significant and fatal. The patient died on 14Apr2021. The cause of death was reported as cardiac arrest. An autopsy was not performed. No follow-up attempts are possible; information about batch number cannot be obtained.; Reported Cause(s) of Death: Cardiac arrest


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