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From the 11/26/2021 release of VAERS data:

This is VAERS ID 414753

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Case Details

VAERS ID: 414753 (history)  
Form: Version 1.0  
Age: 36.0  
Sex: Male  
Location: Utah  
   Days after vaccination:3
Submitted: 2011-01-15
   Days after onset:30
Entered: 2011-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: Private
Symptoms: Abdominal distension, Cardiac arrest, Death, Depressed level of consciousness, Dyspnoea, Headache, Hyperhidrosis, Increased bronchial secretion, Nasopharyngitis, Nausea, Pain, Pulse abnormal, Resuscitation, Ventricular fibrillation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (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), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2010-12-20
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Fentanyl patch 100 mcg 1 patch every 2 days Oxycodone 30 mg 1 q 3 hrs prn pain Midodrine 10 mg 1 q d Captopril 12.5 mg 1/2 tab q 8 hrs Fludrocortisone 0.1 mg 1 q d Omeprazole 40 mg 1 q d Paxil 40 mg 1 q d Clonazepam 1 mg 1-2 q hs prn insomn
Current Illness: Cellulitis, abdomen, at PEG tube site. Afebrile
Preexisting Conditions: Chronic illnesses: Muscular Dystrophy, Limb girdle type Quadriplegia Dysphagia requiring feeding tube Chronic respiratory failure requiring ventilator support. Chronic hypoxemia. Chronic right pleural effusion. History of recurrent pneumonia. Congestive heart failure Chronic pain requiring chronic Chronic anemia Chronic depression and anxiety
Diagnostic Lab Data:
CDC Split Type:

Write-up: 12/16/2010. Patient''s wife called to report that he developed nausea, headache, sweats, aching, cold two days ago (1 day after the flu vaccine was administered). On 12/15/10 he had more difficulty breathing but didn''t mention this on 12/16/10 although he still had body aches. I recommended that he receive ibuprofen 800 mg tid until the symptoms subsided. Go to ER for increased difficulty breathing. 12/20/10. Hospital ED physician called to report that patient was found by his wife in the morning to be difficult to arouse. His abdomen was distended and he had nausea with increased secretions. 911 was called. They found his pulse to be thready and while being transported to the ER went into ventricular fibrillation and then asystole. A full code was done in the ER but they were unable to resuscitate him and he died.

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