| VAERS ID: |
26713 (history) |
| Form: |
Version 1.0 |
| Age: |
77.0 |
| Sex: |
Male |
| Location: |
Maryland |
| Vaccinated: | 1990-10-02 |
| Onset: | 1990-10-02 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
1990-11-21 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| FLU3: INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS |
02580P / UNK |
- / IM |
Administered by: Unknown Purchased by: Unknown
Symptoms: Apnoea,
Cardiac arrest,
Pneumonia,
Shock
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Hypovolaemic shock conditions (narrow), Toxic-septic shock conditions (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypoglycaemic and neurogenic shock conditions (narrow), Acute central respiratory depression (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (narrow), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 1990-10-09
Days after onset: 7
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: ~ ()~~~In patient
Other Medications:
Current Illness:
Preexisting Conditions: Pt hx of COPD, CABG, Chronic renal fialure, had flu shots in the past without problems.
Allergies:
Diagnostic Lab Data:
CDC Split Type: 904090003
Write-up: Pt vaccinated with Fluogen 10-2-90 & on 10-7-90 had nausea. On 10-8-90, had dyspnea & "a lump in his chest" seen in ER; Dx as having RLL infiltrate & R/O AMI. Had respiratory failure & cardiac arrest & died on 10-9-90. |
