| VAERS ID: |
28340 (history) |
| Form: |
Version 1.0 |
| Age: |
58.0 |
| Sex: |
Male |
| Location: |
North Carolina |
| Vaccinated: | 1990-11-09 |
| Onset: | 1990-11-20 |
| Days after vaccination: | 11 |
| Submitted: |
1991-02-14 |
| Days after onset: | 86 |
| Entered: |
1991-02-18 |
| Days after submission: | 4 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| FLU3: INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS |
PD02680P / UNK |
LA / IM |
Administered by: Other Purchased by: Public
Symptoms: Asthenia,
Back pain,
Guillain-Barre syndrome,
Paralysis
SMQs:, Peripheral neuropathy (narrow), Retroperitoneal fibrosis (broad), Guillain-Barre syndrome (narrow), Noninfectious encephalitis (broad), Demyelination (narrow), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Immune-mediated/autoimmune disorders (narrow)
Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, ? days
Extended hospital stay? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: Information from hosp. has not yet been received.
CDC Split Type:
Write-up: 20Nov90 pt developing back pain /w radiation down legs, weakness & some paralysis developed. Was evaluated @ Hosp. DX of Guillian Barre made Dec90. Was allowed to return to full duty @ work 4Feb91 |
