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This is VAERS ID 27639

Case Details

VAERS ID: 27639 (history)  
Form: Version 1.0  
Age:   
Sex: Female  
Location: Tennessee  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 1990-12-26
Entered: 1991-01-29
   Days after submission:34
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLU-IMUNE) / LEDERLE LABORATORIES - / UNK - / -

Administered by: Other       Purchased by: Other
Symptoms: Dyspnoea, Pyrexia
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness:
Preexisting Conditions: Bronchiectasis
Allergies:
Diagnostic Lab Data:
CDC Split Type: 910003501

Write-up: 4-5 hrs after receiving Influenza vaccine, pt experienced respiratory distress & fever of 105. Hospitalized for 3 days.


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