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This is VAERS ID 199311

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History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 199311
VAERS Form:
Age:53.0
Sex:Male
Location:Texas
Vaccinated:2002-11-19
Onset:2002-11-20
Submitted:2003-03-11
Entered:2003-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (FLUZONE) / AVENTIS PASTEUR, U0983AA / - - / -

Administered by: Military      Purchased by: Unknown
Symptoms: APNEA, FLU SYND, ANXIETY, CHOLECYST, FIBRO LUNG

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 94     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: The 60 day follow up received states polymyositis, interstial lung disease-receiving chemotherapy and steroids. Required to use oxygen 24/7. Readmitted to hospital-3 wk stay-8 days in ICU on ventilator. Must now consider medical retirement.


Changed on 12/8/2009

VAERS ID: 199311 Before After
VAERS Form:
Age:53.0
Sex:Male
Location:Texas
Vaccinated:2002-11-19
Onset:2002-11-20
Submitted:2003-03-11
Entered:2003-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (FLUZONE) INFLUENZA (SEASONAL) (FLUZONE) / AVENTIS PASTEUR, AVENTIS PASTEUR U0983AA / - - / -

Administered by: Military      Purchased by: Unknown Military
Symptoms: Anxiety, Apnoea, Cholecystitis, Goitre, Influenza like illness, Leukocytosis, Lung disorder, Otitis media, Pain, Pharyngitis, Pneumonia, Pneumonitis, Polymyositis, Pulmonary fibrosis, Rhinitis, Sepsis, APNEA, FLU SYND, ANXIETY, CHOLECYST, FIBRO LUNG

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 94     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Several negative-will provide data upon request
CDC 'Split Type':

Write-up: Body ache, flu-like symptoms that rapidly progressed. Was diagnosed with polymyositis and desquamative interstitial pneumonitis. The discharge summary states polymyositis, pulmonary fibrosis, pneumonia, staph aureus, bacteremia, cholecystitis, respiratory failure, anxiety disorder, and leukocytosis. The 60 day follow up received states polymyositis, interstial lung disease-receiving chemotherapy and steroids. Required to use oxygen 24/7. Readmitted to hospital-3 wk stay-8 days in ICU on ventilator. Must now consider medical retirement. The follow up received on 3/31/03 states, "triggered: polymyositis, interstitial lung disease, MRSA, respiratory failure, original diagnosis congestive heart failure, 94 days in hospital."


Changed on 1/5/2010

VAERS ID: 199311 Before After
VAERS Form:
Age:53.0
Sex:Male
Location:Texas
Vaccinated:2002-11-19
Onset:2002-11-20
Submitted:2003-03-11
Entered:2003-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUZONE) / AVENTIS PASTEUR SANOFI PASTEUR U0983AA / - - / -

Administered by: Military      Purchased by: Military
Symptoms: Anxiety, Apnoea, Cholecystitis, Goitre, Influenza like illness, Leukocytosis, Lung disorder, Myositis, Otitis media, Pain, Pharyngitis, Pneumonia, Pneumonitis, Polymyositis, Pulmonary fibrosis, Rhinitis, Sepsis

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 94     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Several negative-will provide data upon request
CDC 'Split Type':

Write-up: Body ache, flu-like symptoms that rapidly progressed. Was diagnosed with polymyositis and desquamative interstitial pneumonitis. The discharge summary states polymyositis, pulmonary fibrosis, pneumonia, staph aureus, bacteremia, cholecystitis, respiratory failure, anxiety disorder, and leukocytosis. The 60 day follow up received states polymyositis, interstial lung disease-receiving chemotherapy and steroids. Required to use oxygen 24/7. Readmitted to hospital-3 wk stay-8 days in ICU on ventilator. Must now consider medical retirement. The follow up received on 3/31/03 states, "triggered: polymyositis, interstitial lung disease, MRSA, respiratory failure, original diagnosis congestive heart failure, 94 days in hospital."


Changed on 7/7/2013

VAERS ID: 199311 Before After
VAERS Form:
Age:53.0
Sex:Male
Location:Texas
Vaccinated:2002-11-19
Onset:2002-11-20
Submitted:2003-03-11
Entered:2003-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U0983AA / - - / -
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U0983AA / - - / -

Administered by: Military      Purchased by: Military
Symptoms: Anxiety, Apnoea, Cholecystitis, Goitre, Influenza like illness, Leukocytosis, Lung disorder, Myositis, Otitis media, Pain, Pharyngitis, Pneumonia, Pneumonitis, Polymyositis, Pulmonary fibrosis, Rhinitis, Sepsis

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 94     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Several negative-will provide data upon request
CDC 'Split Type':

Write-up: Body ache, flu-like symptoms that rapidly progressed. Was diagnosed with polymyositis and desquamative interstitial pneumonitis. The discharge summary states polymyositis, pulmonary fibrosis, pneumonia, staph aureus, bacteremia, cholecystitis, respiratory failure, anxiety disorder, and leukocytosis. The 60 day follow up received states polymyositis, interstial lung disease-receiving chemotherapy and steroids. Required to use oxygen 24/7. Readmitted to hospital-3 wk stay-8 days in ICU on ventilator. Must now consider medical retirement. The follow up received on 3/31/03 states, "triggered: polymyositis, interstitial lung disease, MRSA, respiratory failure, original diagnosis congestive heart failure, 94 days in hospital."


Changed on 9/14/2017

VAERS ID: 199311 Before After
VAERS Form:(blank) 1
Age:53.0
Sex:Male
Location:Texas
Vaccinated:2002-11-19
Onset:2002-11-20
Submitted:2003-03-11
Entered:2003-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U0983AA / - UNK - / -

Administered by: Military      Purchased by: Military
Symptoms: Anxiety, Apnoea, Cholecystitis, Goitre, Influenza like illness, Leukocytosis, Lung disorder, Myositis, Otitis media, Pain, Pharyngitis, Pneumonia, Pneumonitis, Polymyositis, Pulmonary fibrosis, Rhinitis, Sepsis

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 94     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Several negative-will provide data upon request
CDC 'Split Type':

Write-up: Body ache, flu-like symptoms that rapidly progressed. Was diagnosed with polymyositis and desquamative interstitial pneumonitis. The discharge summary states polymyositis, pulmonary fibrosis, pneumonia, staph aureus, bacteremia, cholecystitis, respiratory failure, anxiety disorder, and leukocytosis. The 60 day follow up received states polymyositis, interstial lung disease-receiving chemotherapy and steroids. Required to use oxygen 24/7. Readmitted to hospital-3 wk stay-8 days in ICU on ventilator. Must now consider medical retirement. The follow up received on 3/31/03 states, "triggered: polymyositis, interstitial lung disease, MRSA, respiratory failure, original diagnosis congestive heart failure, 94 days in hospital."


Changed on 2/14/2018

VAERS ID: 199311 Before After
VAERS Form:1
Age:53.0
Sex:Male
Location:Texas
Vaccinated:2002-11-19
Onset:2002-11-20
Submitted:2003-03-11
Entered:2003-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U0983AA / UNK - / -

Administered by: Military      Purchased by: Military
Symptoms: Anxiety, Apnoea, Cholecystitis, Goitre, Influenza like illness, Leukocytosis, Lung disorder, Myositis, Otitis media, Pain, Pharyngitis, Pneumonia, Pneumonitis, Polymyositis, Pulmonary fibrosis, Rhinitis, Sepsis

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 94     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Several negative-will provide data upon request
CDC 'Split Type':

Write-up: Body ache, flu-like symptoms that rapidly progressed. Was diagnosed with polymyositis and desquamative interstitial pneumonitis. The discharge summary states polymyositis, pulmonary fibrosis, pneumonia, staph aureus, bacteremia, cholecystitis, respiratory failure, anxiety disorder, and leukocytosis. The 60 day follow up received states polymyositis, interstial lung disease-receiving chemotherapy and steroids. Required to use oxygen 24/7. Readmitted to hospital-3 wk stay-8 days in ICU on ventilator. Must now consider medical retirement. The follow up received on 3/31/03 states, "triggered: polymyositis, interstitial lung disease, MRSA, respiratory failure, original diagnosis congestive heart failure, 94 days in hospital."


Changed on 6/14/2018

VAERS ID: 199311 Before After
VAERS Form:1
Age:53.0
Sex:Male
Location:Texas
Vaccinated:2002-11-19
Onset:2002-11-20
Submitted:2003-03-11
Entered:2003-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U0983AA / UNK - / -

Administered by: Military      Purchased by: Military
Symptoms: Anxiety, Apnoea, Cholecystitis, Goitre, Influenza like illness, Leukocytosis, Lung disorder, Myositis, Otitis media, Pain, Pharyngitis, Pneumonia, Pneumonitis, Polymyositis, Pulmonary fibrosis, Rhinitis, Sepsis

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 94     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Several negative-will provide data upon request
CDC 'Split Type':

Write-up: Body ache, flu-like symptoms that rapidly progressed. Was diagnosed with polymyositis and desquamative interstitial pneumonitis. The discharge summary states polymyositis, pulmonary fibrosis, pneumonia, staph aureus, bacteremia, cholecystitis, respiratory failure, anxiety disorder, and leukocytosis. The 60 day follow up received states polymyositis, interstial lung disease-receiving chemotherapy and steroids. Required to use oxygen 24/7. Readmitted to hospital-3 wk stay-8 days in ICU on ventilator. Must now consider medical retirement. The follow up received on 3/31/03 states, "triggered: polymyositis, interstitial lung disease, MRSA, respiratory failure, original diagnosis congestive heart failure, 94 days in hospital."


Changed on 8/14/2018

VAERS ID: 199311 Before After
VAERS Form:1
Age:53.0
Sex:Male
Location:Texas
Vaccinated:2002-11-19
Onset:2002-11-20
Submitted:2003-03-11
Entered:2003-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U0983AA / UNK - / -

Administered by: Military      Purchased by: Military
Symptoms: Anxiety, Apnoea, Cholecystitis, Goitre, Influenza like illness, Leukocytosis, Lung disorder, Myositis, Otitis media, Pain, Pharyngitis, Pneumonia, Pneumonitis, Polymyositis, Pulmonary fibrosis, Rhinitis, Sepsis

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 94     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Several negative-will provide data upon request
CDC 'Split Type':

Write-up: Body ache, flu-like symptoms that rapidly progressed. Was diagnosed with polymyositis and desquamative interstitial pneumonitis. The discharge summary states polymyositis, pulmonary fibrosis, pneumonia, staph aureus, bacteremia, cholecystitis, respiratory failure, anxiety disorder, and leukocytosis. The 60 day follow up received states polymyositis, interstial lung disease-receiving chemotherapy and steroids. Required to use oxygen 24/7. Readmitted to hospital-3 wk stay-8 days in ICU on ventilator. Must now consider medical retirement. The follow up received on 3/31/03 states, "triggered: polymyositis, interstitial lung disease, MRSA, respiratory failure, original diagnosis congestive heart failure, 94 days in hospital."


Changed on 9/14/2018

VAERS ID: 199311 Before After
VAERS Form:1
Age:53.0
Sex:Male
Location:Texas
Vaccinated:2002-11-19
Onset:2002-11-20
Submitted:2003-03-11
Entered:2003-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U0983AA / UNK - / -

Administered by: Military      Purchased by: Military
Symptoms: Anxiety, Apnoea, Cholecystitis, Goitre, Influenza like illness, Leukocytosis, Lung disorder, Myositis, Otitis media, Pain, Pharyngitis, Pneumonia, Pneumonitis, Polymyositis, Pulmonary fibrosis, Rhinitis, Sepsis

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 94     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Several negative-will provide data upon request
CDC 'Split Type':

Write-up: Body ache, flu-like symptoms that rapidly progressed. Was diagnosed with polymyositis and desquamative interstitial pneumonitis. The discharge summary states polymyositis, pulmonary fibrosis, pneumonia, staph aureus, bacteremia, cholecystitis, respiratory failure, anxiety disorder, and leukocytosis. The 60 day follow up received states polymyositis, interstial lung disease-receiving chemotherapy and steroids. Required to use oxygen 24/7. Readmitted to hospital-3 wk stay-8 days in ICU on ventilator. Must now consider medical retirement. The follow up received on 3/31/03 states, "triggered: polymyositis, interstitial lung disease, MRSA, respiratory failure, original diagnosis congestive heart failure, 94 days in hospital."


Changed on 10/14/2018

VAERS ID: 199311 Before After
VAERS Form:1
Age:53.0
Sex:Male
Location:Texas
Vaccinated:2002-11-19
Onset:2002-11-20
Submitted:2003-03-11
Entered:2003-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U0983AA / UNK - / -

Administered by: Military      Purchased by: Military
Symptoms: Anxiety, Apnoea, Cholecystitis, Goitre, Influenza like illness, Leukocytosis, Lung disorder, Myositis, Otitis media, Pain, Pharyngitis, Pneumonia, Pneumonitis, Polymyositis, Pulmonary fibrosis, Rhinitis, Sepsis

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 94     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Several negative-will provide data upon request
CDC 'Split Type':

Write-up: Body ache, flu-like symptoms that rapidly progressed. Was diagnosed with polymyositis and desquamative interstitial pneumonitis. The discharge summary states polymyositis, pulmonary fibrosis, pneumonia, staph aureus, bacteremia, cholecystitis, respiratory failure, anxiety disorder, and leukocytosis. The 60 day follow up received states polymyositis, interstial lung disease-receiving chemotherapy and steroids. Required to use oxygen 24/7. Readmitted to hospital-3 wk stay-8 days in ICU on ventilator. Must now consider medical retirement. The follow up received on 3/31/03 states, "triggered: polymyositis, interstitial lung disease, MRSA, respiratory failure, original diagnosis congestive heart failure, 94 days in hospital."


Changed on 12/24/2020

VAERS ID: 199311 Before After
VAERS Form:1
Age:53.0
Sex:Male
Location:Texas
Vaccinated:2002-11-19
Onset:2002-11-20
Submitted:2003-03-11
Entered:2003-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U0983AA / UNK - / -

Administered by: Military      Purchased by: Military
Symptoms: Anxiety, Apnoea, Cholecystitis, Goitre, Influenza like illness, Leukocytosis, Lung disorder, Myositis, Otitis media, Pain, Pharyngitis, Pneumonia, Pneumonitis, Polymyositis, Pulmonary fibrosis, Rhinitis, Sepsis

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 94     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Several negative-will provide data upon request
CDC 'Split Type':

Write-up: Body ache, flu-like symptoms that rapidly progressed. Was diagnosed with polymyositis and desquamative interstitial pneumonitis. The discharge summary states polymyositis, pulmonary fibrosis, pneumonia, staph aureus, bacteremia, cholecystitis, respiratory failure, anxiety disorder, and leukocytosis. The 60 day follow up received states polymyositis, interstial lung disease-receiving chemotherapy and steroids. Required to use oxygen 24/7. Readmitted to hospital-3 wk stay-8 days in ICU on ventilator. Must now consider medical retirement. The follow up received on 3/31/03 states, "triggered: polymyositis, interstitial lung disease, MRSA, respiratory failure, original diagnosis congestive heart failure, 94 days in hospital."


Changed on 12/30/2020

VAERS ID: 199311 Before After
VAERS Form:1
Age:53.0
Sex:Male
Location:Texas
Vaccinated:2002-11-19
Onset:2002-11-20
Submitted:2003-03-11
Entered:2003-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U0983AA / UNK - / -

Administered by: Military      Purchased by: Military
Symptoms: Anxiety, Apnoea, Cholecystitis, Goitre, Influenza like illness, Leukocytosis, Lung disorder, Myositis, Otitis media, Pain, Pharyngitis, Pneumonia, Pneumonitis, Polymyositis, Pulmonary fibrosis, Rhinitis, Sepsis

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 94     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Several negative-will provide data upon request
CDC 'Split Type':

Write-up: Body ache, flu-like symptoms that rapidly progressed. Was diagnosed with polymyositis and desquamative interstitial pneumonitis. The discharge summary states polymyositis, pulmonary fibrosis, pneumonia, staph aureus, bacteremia, cholecystitis, respiratory failure, anxiety disorder, and leukocytosis. The 60 day follow up received states polymyositis, interstial lung disease-receiving chemotherapy and steroids. Required to use oxygen 24/7. Readmitted to hospital-3 wk stay-8 days in ICU on ventilator. Must now consider medical retirement. The follow up received on 3/31/03 states, "triggered: polymyositis, interstitial lung disease, MRSA, respiratory failure, original diagnosis congestive heart failure, 94 days in hospital."


Changed on 5/7/2021

VAERS ID: 199311 Before After
VAERS Form:1
Age:53.0
Sex:Male
Location:Texas
Vaccinated:2002-11-19
Onset:2002-11-20
Submitted:2003-03-11
Entered:2003-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U0983AA / UNK - / -

Administered by: Military      Purchased by: Military
Symptoms: Anxiety, Apnoea, Cholecystitis, Goitre, Influenza like illness, Leukocytosis, Lung disorder, Myositis, Otitis media, Pain, Pharyngitis, Pneumonia, Pneumonitis, Polymyositis, Pulmonary fibrosis, Rhinitis, Sepsis

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 94     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Several negative-will provide data upon request
CDC 'Split Type':

Write-up: Body ache, flu-like symptoms that rapidly progressed. Was diagnosed with polymyositis and desquamative interstitial pneumonitis. The discharge summary states polymyositis, pulmonary fibrosis, pneumonia, staph aureus, bacteremia, cholecystitis, respiratory failure, anxiety disorder, and leukocytosis. The 60 day follow up received states polymyositis, interstial lung disease-receiving chemotherapy and steroids. Required to use oxygen 24/7. Readmitted to hospital-3 wk stay-8 days in ICU on ventilator. Must now consider medical retirement. The follow up received on 3/31/03 states, "triggered: polymyositis, interstitial lung disease, MRSA, respiratory failure, original diagnosis congestive heart failure, 94 days in hospital."


Changed on 5/21/2021

VAERS ID: 199311 Before After
VAERS Form:1
Age:53.0
Sex:Male
Location:Texas
Vaccinated:2002-11-19
Onset:2002-11-20
Submitted:2003-03-11
Entered:2003-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U0983AA / UNK - / -

Administered by: Military      Purchased by: Military
Symptoms: Anxiety, Apnoea, Cholecystitis, Goitre, Influenza like illness, Leukocytosis, Lung disorder, Myositis, Otitis media, Pain, Pharyngitis, Pneumonia, Pneumonitis, Polymyositis, Pulmonary fibrosis, Rhinitis, Sepsis

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 94     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Several negative-will provide data upon request
CDC 'Split Type':

Write-up: Body ache, flu-like symptoms that rapidly progressed. Was diagnosed with polymyositis and desquamative interstitial pneumonitis. The discharge summary states polymyositis, pulmonary fibrosis, pneumonia, staph aureus, bacteremia, cholecystitis, respiratory failure, anxiety disorder, and leukocytosis. The 60 day follow up received states polymyositis, interstial lung disease-receiving chemotherapy and steroids. Required to use oxygen 24/7. Readmitted to hospital-3 wk stay-8 days in ICU on ventilator. Must now consider medical retirement. The follow up received on 3/31/03 states, "triggered: polymyositis, interstitial lung disease, MRSA, respiratory failure, original diagnosis congestive heart failure, 94 days in hospital."

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