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This is VAERS ID 36644

Case Details

VAERS ID: 36644 (history)  
Form: Version 1.0  
Age: 72.0  
Sex: Male  
Location: Georgia  
Vaccinated:1991-09-23
Onset:1991-09-25
   Days after vaccination:2
Submitted: 1991-10-01
   Days after onset:6
Entered: 1991-11-26
   Days after submission:56
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS 0127P / 3 LA / UN

Administered by: Unknown       Purchased by: Unknown
Symptoms: Dehydration, Hypoxia, Malaise, Respiratory disorder, Ventricular fibrillation
SMQs:, Torsade de pointes/QT prolongation (broad), Asthma/bronchospasm (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Infective pneumonia (broad), Dehydration (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1991-09-28
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Gastroenteritis
Preexisting Conditions: moderate to marked atherosclerosis, coronary artery
Allergies:
Diagnostic Lab Data:
CDC Split Type: GA91311

Write-up: Pt became ill 2 days following inject; admitted to hosp because of dehydration; died 28SEP91; death certificate-ventricular fibrillation, hypoxia, aspiration, gastric contents;


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