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This is VAERS ID 42021

Case Details

VAERS ID: 42021 (history)  
Form: Version 1.0  
Age: 62.0  
Sex: Male  
Location: California  
Vaccinated:1991-11-07
Onset:0000-00-00
Submitted: 1992-03-26
Entered: 1992-05-18
   Days after submission:52
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLU-IMUNE) / LEDERLE LABORATORIES 312976 / UNK - / IM

Administered by: Private       Purchased by: Other
Symptoms: Asthenia, Cough, Pyrexia, Tachycardia, Weight decreased
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Guillain-Barre syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: NA~ ()~~~In patient
Other Medications: NONE
Current Illness: Stage 0 chronic lymphocytic leukemia
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: CBC, Chem-20, GGTP, Febrile agglutinins, CXR, echo of heart, CAT Scan of chest; CAT Scan of abdomin & pelvis; hepatitis profile; bone marrow; EKG;
CDC Split Type: 920078001

Write-up: Pt recvd vax 7NOV91 & began exp tachycardia, exhaustion, weight loss of 25 lbs in 2 mos, low grade fever that subsided, & dry cough (persists); All lab test nl; pt has pre-existing stage 0 chronic lymphocytic leukemia;


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