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From the 11/12/2021 release of VAERS data:

This is VAERS ID 418868

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Case Details

VAERS ID: 418868 (history)  
Form: Version 1.0  
Age: 68.0  
Sex: Male  
Location: Montana  
Vaccinated:2011-02-10
Onset:2011-02-10
   Days after vaccination:0
Submitted: 2011-03-16
   Days after onset:33
Entered: 2011-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS AC52BO67GA / 1 LA / IM

Administered by: Private       Purchased by: Other
Symptoms: Chills, Death, Malaise, Nausea, Pain, Pneumonia, Pyrexia, Respiratory tract congestion
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2011-02-20
   Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Pradaxa 150 mg daily Lipitor 10 mg daily Lisinopril 20 mg daily Diltiazem 180 mg daily Hctz 12.5 mg daily Zyrtec 10 mg daily
Current Illness: None reported by the patient
Preexisting Conditions: Hyperlipidemia Chronic Lymphoid Leukemia Hypertension Atrial Fib Chronic allergic Rhinitis
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Tdap vaccine was givin in the clinic. The patient called on 2/15/2011 and reported that within 2-3 hours of the injection he was feverish, chilled, nauseated, had body aches, and chest congestion and overall felt very ill. Patient died on 2/20/2011 of an unusual strain of pneumonia.


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