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From the 9/17/2021 release of VAERS data:

This is VAERS ID 1404296



Case Details

VAERS ID: 1404296 (history)  
Form: Version 2.0  
Age: 30.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-06-01
Onset:2021-06-01
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EY5456 / 1 - / -

Administered by: Other       Purchased by: ?
Symptoms: Loss of consciousness, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: GBPFIZER INC2021640588

Write-up: Blacked Out; Syncope; This is a spontaneous report from a contactable physician received from the Regulatory Agency (RA). The regulatory authority report number is GB-MHRA-WEBCOVID-202106011136336720-XFAXH, Safety Report Unique Identifier GB-MHRA-ADR 25397249. A 30-year-old male patient received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on 01Jun2021 10:57 (Lot Number: EY5456) (at the age of 30-years-old) as 1ST DOSE, SINGLE for COVID-19 immunisation The patient medical history and concomitant medications were not reported. Patient has not had symptoms associated with COVID-19, not had a COVID-19 test, and unsure if patient was enrolled in clinical trial. On 01Jun2021, the patient experienced syncope and blacked out. The clinical course was reported as follows: Vaccine given at 10:57 ATRP (as reported) at 11:05 as syncopal episode. Blacked out and woke up on the floor. No preceding symptoms, no seizure activity reported, afterwards, alert and orientated, one inch superficial graze above right eye. The events were considered non serious by MHRA; Pfizer assessed the events as serious, medically significant. The outcome of the events was recovered on 01Jun2021. Report not related to possible blood clots or low platelet counts. No follow-up attempts are possible. No further information is Expected.


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