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This is VAERS ID 153914

Case Details

VAERS ID: 153914 (history)  
Form: Version 1.0  
Age: 61.0  
Sex: Male  
Location: Michigan  
   Days after vaccination:37
Submitted: 2000-05-30
   Days after onset:17
Entered: 2000-06-12
   Days after submission:13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: Other
Symptoms: Arteritis, Arthralgia, Death, Fatigue, Myocardial infarction, Oedema peripheral, Polyarteritis nodosa, Vasculitis
SMQs:, Cardiac failure (broad), Angioedema (broad), Interstitial lung disease (broad), Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Optic nerve disorders (broad), Eosinophilic pneumonia (broad), Vasculitis (narrow), Arthritis (broad), Immune-mediated/autoimmune disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Diagnostic Lab Data: CBC, chemistry, X-ray
CDC Split Type:

Write-up: Received injection in 2 stages. On May 13, 2000 hands, forearms swollen, joints ached, shoulder sore, very tired. Used Benadryl also was given Cicsorex for pain. That did not help. Was given Advil 800 mg. As of 6/4/2000 pt still has fatigue, swelling and pain.

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