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This is VAERS ID 162101

Case Details

VAERS ID: 162101 (history)  
Form: Version 1.0  
Age: 83.0  
Sex: Male  
Location: Iowa  
Vaccinated:1999-10-14
Onset:1999-10-29
   Days after vaccination:15
Submitted: 2000-11-13
   Days after onset:381
Entered: 2000-11-17
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUSHIELD) / PFIZER/WYETH 4998217 / 1 - / IM

Administered by: Unknown       Purchased by: Unknown
Symptoms: Cough, Haemoptysis
SMQs:, Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Infective pneumonia (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 1999-12-23
   Days after onset: 55
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 11 days
   Extended hospital stay? No
Previous Vaccinations: Cough~Influenza (Seasonal) (no brand name)~~82.00~In Patient
Other Medications: Accupred, Lasix, K-Dur, Prilosec
Current Illness:
Preexisting Conditions: Hypertension, CHF, hypercholesterolemia,
Allergies:
Diagnostic Lab Data: X-rays, lung scrub, tests (nos).
CDC Split Type:

Write-up: Pt received flu shot on 10/14/1999, developed severe cough 10/29, was coughing up blood on 10/30. Was hospitalized 10/30 and received transfusion on 10/31. Tests were conducted and he was referred on 11/14. Pt died on 12/23/99.


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