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This is VAERS ID 37817

Case Details

VAERS ID: 37817 (history)  
Form: Version 1.0  
Age: 46.0  
Sex: Male  
Location: Connecticut  
Vaccinated:1991-11-18
Onset:1991-11-18
   Days after vaccination:0
Submitted: 1991-11-19
   Days after onset:1
Entered: 1991-12-09
   Days after submission:20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLUX: INFLUENZA (SEASONAL) (NO BRAND NAME) / PFIZER/WYETH 4918169 / 1 - / IM A

Administered by: Public       Purchased by: Public
Symptoms: Anaphylactoid reaction, Apnoea, Asthma, Bronchitis, Cardiac arrest, Condition aggravated
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Asthma/bronchospasm (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Acute central respiratory depression (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypersensitivity (narrow), Respiratory failure (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 1991-11-18
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: UNK
Current Illness: UNK
Preexisting Conditions: pt had a hx of chronic, controlled asthma, & was possibly taking meds for this; allergies;
Allergies:
Diagnostic Lab Data:
CDC Split Type: 891325001J

Write-up: Pt recvd flu vax on 18NOV91 between 11AM & 2PM; that night pt "arrested" @ home; EMS were summoned, but pt died; pt suffered an asthma attack; no autopsy was performed; Prior to vax survey form pt didn''t indicate allergy to eggs;


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