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

This is VAERS ID 1380364

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Case Details

VAERS ID: 1380364 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Foreign  
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-06-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: Cardio-respiratory arrest, Death, Pyrexia
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-30
   Days after onset: 1
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: Dialysis; Renal failure chronic
Diagnostic Lab Data:
CDC Split Type: JPPFIZER INC2021630586

Write-up: unknown cause of death; Cardio-respiratory arrest; pyrexia; This is a spontaneous case from a contactable physician received via a Pfizer sales representative. An 84-year-old female patient received bnt162b2 (COMIRNATY) via an unspecified route of administration on 28May2021 (at the age of 84-year-old) (Batch/Lot number was not reported) as single dose (unknown if first or second dose) for COVID-19 immunisation. Relevant medical history included chronic renal failure, for which she was receiving dialysis. Concomitant medications were not reported. Body temperature before vaccination was not provided. The patient family history was not provided. On 29May2021 (one day after the vaccination), the patient was admitted to the hospital (no reason for hospitalization reported). On 30May2021 (2 days after the vaccination), the patient experienced cardio-respiratory arrest and died. The course of the event was as follows: on 28May2021 (the day of vaccination), the patient received BNT162b2 vaccination. On 29May2021 (one day after vaccination), although the patient had pyrexia, she visited the reporting hospital for receiving dialysis. The patient was admitted to the hospital. On 30May2021 (2 days after vaccination), the patient experienced cardio-respiratory arrest. The outcome of the event was fatal. The reporting physician classified the event as serious (death) and assessed that the event was probably related to BNT162b2. The cause of death was reported as ''Unknown''. It was not reported whether an autopsy was performed. The information on the batch number has been requested.; Sender''s Comments: Based on the information currently available, the pre-existing chronic renal failure might have contributed to the clinical course leading to the patient''s demise. However, unless further information regarding specific cause of death provided, at present, the reported event death, cause unknown, is assessed as possibly related to suspect drug, as a cautionary measure and for reporting purposes. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics Committees, and Investigators, as appropriate and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics Committees, and Investigators, as appropriate.; Reported Cause(s) of Death: unknown cause of death

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