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From the 11/26/2021 release of VAERS data:

This is VAERS ID 1428988

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Case Details

VAERS ID: 1428988 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Foreign  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: Apnoea, Blood pressure measurement, Body temperature, Cardio-respiratory arrest
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 (narrow), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Anaemia (She received the treatment Apr2009); Arteriosclerosis obliterans (She received the treatment Apr2009); Arteriosclerosis obliterans; Cardiac failure (She received the treatment Apr2009); Chronic kidney disease (She received the treatment Apr2009); Dementia (She received the treatment Apr2009); Dyspnoea (required hospital treatment); Femoral neck fracture (She received the treatment Apr2009); Hypertension (She received the treatment Apr2009); Left heart failure (required hospital treatment); Osteoarthritis of lumbar spine (She received the treatment Apr2009)
Diagnostic Lab Data: Test Date: 20210609; Test Name: Blood pressure; Result Unstructured Data: Test Result:136/66; Test Date: 20210609; Test Name: Body temperature; Result Unstructured Data: Test Result:35.8 Centigrade; Comments: Before vaccination
CDC Split Type: JPPFIZER INC2021692033

Write-up: Cardio-respiratory arrest; Apnoea; This is a spontaneous report from a contactable physician received via COVID-19 Adverse Event Self-Reporting Solution (COVAES). The report is also received from the Regulatory authority via regulatory authority report. RA number is v21113132. The patient was a non-pregnant 87-year and 1-month-old female. Since Apr2009, the patient had received the treatment for hypertension, cardiac failure, chronic kidney disease, anaemia, dementia, osteoarthritis of lumbar spine, status after femoral neck fracture and arteriosclerosis obliterans. The patient was emergently hospitalized for dyspnoea due to left heart failure in Jul2020, and then the presence of arteriosclerosis obliterans was pointed out. While she was using a day-care facility located next to the reporter''s hospital, she was regularly visiting the reporter''s hospital once a month. The patient had no relevant family history. The patient had no allergies to medications, food, or other products. The patient did not receive any other vaccines within 4 weeks prior to the COVID vaccine. The patient received enalapril, furosemide (LASIX), spironolactone, cilnidipine, allopurinol, sarpogrelate, lansoprazole within 2 weeks of vaccination. Prior to vaccination, the patient was not diagnosed with COVID-19. Since the vaccination, the patient has not been tested for COVID-19. On 09Jun2021 at 10:50 (the day of vaccination), the patient received the first single dose of BNT162b2 (COMIRNATY, Solution for injection, Lot number EY5420, Expiration date 31Aug2021) intramuscular in the left arm for COVID-19 immunization. On 09Jun2021 at 18:00 (the day of vaccination), the patient experienced Apnoea which resulted in death. On 09Jun2021 at 19:30 (the day of vaccination), the patient experienced cardio-respiratory arrest which resulted in death. An autopsy was not performed. Additional clinical course was reported as follows: On 09Jun2021, the reporter visited the patient on the day of once-a-week day-care service (the reporter adjusted his schedule). At 09:15, the reporter arrived at the daycare facility, and at 10:50, the reporter gave the vaccination to the patient. At the time of the vaccination (before the vaccination), body temperature was 35.8 degrees Centigrade and blood pressure was 136/66. The reporter observed the patient until the time when the day care service was finished, and during the time, no change was noted in her condition. After a facility member sent her to her house, her care manager visited her house from 17:00 to 17:30, and during the time, her son was talking to the care manager about rental of a welfare equipment such as portable latrine, but there was no change. At 18:00, a staff member received the phone call from her son saying that she might not breathe. Thus, immediately, an emergency service was requested to transfer the patient to a hospital. She was transferred to the hospital by an ambulance. At 19:30, the patient''s death was pronounced. The reporting physician classified the event as serious (fatal outcome) and assessed the causality between the event and BNT162b2 as unassessable. Possible cause of the event was reported as follows: In 2020, the patient was emergently hospitalized for dyspnoea due to left heart failure, therefore, there was a possibility that cardiac failure caused the occurrence of cardio-respiratory arrest.; Reported Cause(s) of Death: Cardio-respiratory arrest; Apnoea

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