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This is VAERS ID 40951

Case Details

VAERS ID: 40951 (history)  
Form: Version 1.0  
Age: 79.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:1991-12-19
Onset:1991-12-27
   Days after vaccination:8
Submitted: 1992-03-24
   Days after onset:88
Entered: 1992-04-01
   Days after submission:8
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 1F21215 / UNK - / IM A

Administered by: Private       Purchased by: Public
Symptoms: Cardiac arrest, Coagulopathy, Dyspnoea, Lactic acidosis, Pharyngitis, Pneumonia, Respiratory disorder, Sepsis
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Agranulocytosis (broad), Lactic acidosis (narrow), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Oropharyngeal infections (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 1992-01-05
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: Chemotherapy w/Cytoxan, Vincristine, Procarbazine, Pred, & Bleomycin
Current Illness: Lymphoma
Preexisting Conditions: lymphoma, leukemia
Allergies:
Diagnostic Lab Data: CXR
CDC Split Type: PA9280

Write-up: 27DEC91 fever, fatigue, weak; 28DEC91 t102, ATB recvd; 31DEC91 fever, cough worse to hosp ER; cxr done; not admitted; 1JAN92 to hosp ER was admitted; heart stopped in ICU died 5JAN92;


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