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

This is VAERS ID 1419900



Case Details

VAERS ID: 1419900 (history)  
Form: Version 2.0  
Age: 16.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-06-04
Onset:2021-06-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0175 / UNK LA / -

Administered by: Private       Purchased by: ?
Symptoms: Loss of consciousness
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), 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: FLONASE [FLUTICASONE PROPIONATE]
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: COVID-19 (Covid-19 prior vaccination); Myotonia congenita (Paramyotonia-congenita)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021665173

Write-up: Passed out 12 hours after receiving the vaccine.; This is a spontaneous report from a contactable consumer(patient). This 16-year-old female patient (not pregnant) received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, lot number EW0175) at single dose via an unknown route in left arm on 04Jun2021 08:30 at 16-year-old for Covid-19 immunization. Medical history included Paramyotonia-congenita. Prior to vaccination, was the patient diagnosed with COVID-19. Patient had no known allergies. Concomitant drug included fluticasone propionate (FLONASE). The patient did not receive any other vaccines within 4 weeks prior to the COVID vaccine. On 04Jun2021 08:00 PM, patient passed out "12 hours" (as reported) after receiving the vaccine. No treatment was received. Outcome of the event was resolved. Since the vaccination, the had not patient been tested for COVID-19. The report was assessed as non-serious.


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