From the 12/30/2020 release of VAERS data:

This is VAERS ID 28380

Case Details

VAERS ID:	28380 (history)
Form:	Version 1.0
Age:	80.0
Sex:	Male
Location:	Michigan

Vaccinated:	1990-10-01
Onset:	1990-10-10
Days after vaccination:	9
Submitted:	1991-02-06
Days after onset:	119
Entered:	1991-02-18
Days after submission:	12

Vaccination / Manufacturer	Lot / Dose	Site / Route
FLUX: INFLUENZA (SEASONAL) (NO BRAND NAME) / PFIZER/WYETH	4908209 / 1	- / IM A

Administered by: Private Purchased by: Private
Symptoms: Influenza, Pharyngitis, Pyrexia, Sepsis
SMQs:, Agranulocytosis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Oropharyngeal infections (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Sepsis (narrow), Opportunistic infections (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, ? days
Extended hospital stay? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: none
Current Illness:
Preexisting Conditions: pt has hx of cerebrovascular accident
Allergies:
Diagnostic Lab Data:
CDC Split Type: 890291003B

Write-up: Pt developed flu like respiratory symptoms nine days /p receiving Flu vax(1990-91 formula).Pt was admitted to acute care facility /w a respiratory infection, sepsis, & T. F/U info,recvd 25Jan91 resulted in reclassification as a 15 day rept

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=28380