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This is VAERS ID 161416

Case Details

VAERS ID: 161416 (history)  
Form: Version 1.0  
Age: 79.0  
Sex: Male  
Location: Illinois  
Vaccinated:2000-10-10
Onset:2000-10-15
   Days after vaccination:5
Submitted: 2000-11-02
   Days after onset:18
Entered: 2000-11-07
   Days after submission:5
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / AVENTIS PASTEUR - / UNK - / IM

Administered by: Other       Purchased by: Unknown
Symptoms: Apnoea, Cardiac failure congestive, Chest X-ray abnormal, Respiratory distress
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Acute central respiratory depression (narrow), 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: 2000-10-16
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: CHF; pneumonia
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Chest X-ray-interstitial infiltrates noted.
CDC Split Type: U2000007672

Write-up: It was reported that a 79 year old male pt received a Fluzone SV ''00-''01 vaccination on 10/10/00. Reportedly, the pt developed respiratory distress and congestive heart failure. The pt was hospitalized in ICU on a ventilator and cease to breath on 10/15/00. Interstitial infiltrates notes on chest X-ray by Pulmonologist. Follow-up from 10/24/00, upon further evaluation is was discovered that the pt died on 10/15/00. Follow-up correspondence received on 11/2/00, it was reported that the pt died on 10/16/00 not on 10/15/00 as previously reported. Additional pt and responsible physician information were also provided.


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