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This is VAERS ID 26655

Case Details

VAERS ID: 26655 (history)  
Form: Version 1.0  
Age: 65.0  
Sex: Female  
Location: Michigan  
Vaccinated:1990-10-18
Onset:1990-10-25
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 1990-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 0F112117 / UNK - / IM

Administered by: Unknown       Purchased by: Unknown
Symptoms: Asthenia, Back pain
SMQs:, Retroperitoneal fibrosis (broad), Guillain-Barre syndrome (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? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: Calan SR 240MG 1/2 tab daily.
Current Illness:
Preexisting Conditions: Hx of hypertension, cigarette smoking.
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt vaccinated with Fluzone 1 wk after injection, had sudden death. 1 & 2 days before death c/o fatigue, low back pain and upper shoulder pain.


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