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This is VAERS ID 160801

Case Details

VAERS ID: 160801 (history)  
Form: Version 1.0  
Age: 87.0  
Sex: Male  
Location: Illinois  
   Days after vaccination:5
Submitted: 2000-10-20
   Days after onset:5
Entered: 2000-10-23
   Days after submission:3
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Unknown       Purchased by: Unknown
Symptoms: Cardiac failure congestive, Chest X-ray abnormal, Respiratory distress
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Acute central respiratory depression (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Diagnostic Lab Data: chest x-ray - interstitial infiltrates
CDC Split Type: U2000007670

Write-up: The pt experienced respiratory distress and congestive heart failure. The pt was hospitalized in ICU on a ventilator and CTB on 10/15/00. Interstitial infiltrates noted on chest x-ray by Pulmonologist.

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