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This is VAERS ID 36249

Case Details

VAERS ID: 36249 (history)  
Form: Version 1.0  
Age: 62.0  
Sex: Male  
Location: Tennessee  
Vaccinated:1991-10-31
Onset:1991-10-31
   Days after vaccination:0
Submitted: 1991-11-04
   Days after onset:4
Entered: 1991-11-12
   Days after submission:8
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLUX: INFLUENZA (SEASONAL) (NO BRAND NAME) / PFIZER/WYETH 4918201 / UNK LA / IM

Administered by: Public       Purchased by: Public
Symptoms: Dizziness, Pharyngitis, Tachycardia, Ventricular fibrillation
SMQs:, Torsade de pointes/QT prolongation (broad), Agranulocytosis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Oropharyngeal infections (narrow), Vestibular disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (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:
Allergies:
Diagnostic Lab Data:
CDC Split Type: TN91209

Write-up: 20 minutes p/immun felt faint that night felt like throat was closing; pt monitors blood pressure monitoring device seemed to go wild; heart beat was fast-160 beats a minutes; fibrillation;


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