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This is VAERS ID 485686

History of Changes from the VAERS Wayback Machine

First Appeared on 3/12/2013

VAERS ID: 485686
VAERS Form:
Age:82.0
Sex:Male
Location:Colorado
Vaccinated:2012-11-15
Onset:0000-00-00
Submitted:2013-02-27
Entered:2013-02-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
VARZOS: ZOSTER (ZOSTAVAX) / MERCK & CO. INC. - / - UN / UN

Administered by: Other      Purchased by: Other
Symptoms: Cardiac arrest, Death, Multi-organ failure

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-12-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: No other medications
Current Illness: Unknown
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': WAES1302USA012087

Write-up: This spontaneous report as received from a consumer refers to an 82 year old male patient. The patient''s medical history and concurrent conditions were not provided. On 15-NOV-2012 the patient was vaccinated with a dose of ZOSTAVAX. Dose, route and lot number were not provided. No concomitant medications were reported. On an unknown date the patient experienced multi-organ failure and cardiac arrest. The outcome of multi-organ failure and cardiac arrest was reported as fatal. The patient died on 13-DEC-2012 at 1515 (military time) in the hospital. The cause of death was reported as cardiac arrest and multi-organ failure, according to the Death Certificate. No reporter causality was provided. Additional information has been requested.


Changed on 5/13/2013

VAERS ID: 485686 Before After
VAERS Form:
Age:82.0
Sex:Male
Location:Colorado
Vaccinated:2012-11-15
Onset:0000-00-00
Submitted:2013-02-27
Entered:2013-02-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS - / - UN / UN
VARZOS: ZOSTER (ZOSTAVAX) / MERCK & CO. INC. - / - 0 UN / UN

Administered by: Other      Purchased by: Other
Symptoms: Cardiac arrest, Death, Multi-organ failure

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-12-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: No other medications
Current Illness: Unknown
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': WAES1302USA012087

Write-up: This spontaneous report as received from a consumer refers to an 82 year old male patient. The patient''s medical history and concurrent conditions were not provided. On 15-NOV-2012 the patient was vaccinated with a dose of ZOSTAVAX. Dose, route and lot number were not provided. No concomitant medications were reported. On an unknown date the patient experienced multi-organ failure and cardiac arrest. The outcome of multi-organ failure and cardiac arrest was reported as fatal. The patient died on 13-DEC-2012 at 1515 (military time) in the hospital. The cause of death was reported as cardiac arrest and multi-organ failure, according to the Death Certificate. No reporter causality was provided. Additional information has been requested.


Changed on 9/17/2013

VAERS ID: 485686 Before After
VAERS Form:
Age:82.0
Sex:Male
Location:Colorado
Vaccinated:2012-11-15
Onset:0000-00-00
Submitted:2013-02-27
Entered:2013-02-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS - / - UN / UN
VARZOS: ZOSTER (ZOSTAVAX) / MERCK & CO. INC. - / 0 UN / UN

Administered by: Other      Purchased by: Other
Symptoms: Acute myocardial infarction, Cardiac arrest, Death, Multi-organ failure

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-12-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: No other medications
Current Illness: Unknown The following information was obtained through follow-up and/or provided by the government. 03/26/13 Valvular heart disease, hypertension chronic with renal disease, chronic stable congestive heart failure with dystolic dysfunction, chronic kidney disease stage III, hyperlipidemia, peripheral vascular disease with carotid disease and atherosclerosis, hyponatremia, mitral regurgitation.
Preexisting Conditions: The following information was obtained through follow-up and/or provided by the government. 03/26/13 PMH: Graves disease, prostate cancer with orchiectomy, atrial fibrillation, stroke, pacemaker, osteoporosis, gastric ulcer, hearing loss. Aortic valve replacement, partial colectomy, vagotomy.
Allergies:
Diagnostic Lab Data: The following information was obtained through follow-up and/or provided by the government. 03/26/13 Labs and Diagnostics: ECG - Abnormal. Chest X-ray - Abnormal. CT Brain - Abnormal. EEG - Abnormal.
CDC 'Split Type': WAES1302USA012087

Write-up: This spontaneous report as received from a consumer refers to an 82 year old male patient. The patient''s medical history and concurrent conditions were not provided. On 15-NOV-2012 the patient was vaccinated with a dose of ZOSTAVAX. Dose, route and lot number were not provided. No concomitant medications were reported. On an unknown date the patient experienced multi-organ failure and cardiac arrest. The outcome of multi-organ failure and cardiac arrest was reported as fatal. The patient died on 13-DEC-2012 at 1515 (military time) in the hospital. The cause of death was reported as cardiac arrest and multi-organ failure, according to the Death Certificate. No reporter causality was provided. Additional information has been requested. The following information was obtained through follow-up and/or provided by the government. 03/26/13 Hospital records, consultations, and discharge summary received. Service dates 12/11/12 to 12/13/12. Diagnosis: MCA Territory Stroke. Respiratory failure. Patient presents with chest pain, planning on heart catherization. Complaints of left arm and shoulder pain, nausea, shortness of breath. Unsucessful cardiac catherization. Non-ST-elevation MI, intra-aortic balloon pump placed in descending aorta and malfunctioned. Developed continuous twitching on right side with myoclonic jerking. Intubation, mechanical ventilation. Unresponsive. Deep tendon reflexes diminished. 8/1/13 Death Certificate received. Final Cause of Death: Multi Organ Failure. Other information abstracted: Cardiac arrest, Non-ST-Elevation Myocardial Infarction.


Changed on 11/13/2013

VAERS ID: 485686 Before After
VAERS Form:
Age:82.0
Sex:Male
Location:Colorado
Vaccinated:2012-11-15
Onset:0000-00-00
Submitted:2013-02-27
Entered:2013-02-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS - / - UN / UN
VARZOS: ZOSTER (ZOSTAVAX) / MERCK & CO. INC. - / 0 UN / UN

Administered by: Other      Purchased by: Other
Symptoms: Acute myocardial infarction, Cardiac arrest, Death, Multi-organ failure

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-12-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: No other medications
Current Illness: Unknown The following information was obtained through follow-up and/or provided by the government. 03/26/13 Valvular heart disease, hypertension chronic with renal disease, chronic stable congestive heart failure with dystolic dysfunction, chronic kidney disease stage III, hyperlipidemia, peripheral vascular disease with carotid disease and atherosclerosis, hyponatremia, mitral regurgitation.
Preexisting Conditions: The following information was obtained through follow-up and/or provided by the government. 03/26/13 PMH: Graves disease, prostate cancer with orchiectomy, atrial fibrillation, stroke, pacemaker, osteoporosis, gastric ulcer, hearing loss. Aortic valve replacement, partial colectomy, vagotomy.
Allergies:
Diagnostic Lab Data: The following information was obtained through follow-up and/or provided by the government. 03/26/13 Labs and Diagnostics: ECG - Abnormal. Chest X-ray - Abnormal. CT Brain - Abnormal. EEG - Abnormal.
CDC 'Split Type': WAES1302USA012087

Write-up: This spontaneous report as received from a consumer refers to an 82 year old male patient. The patient''s medical history and concurrent conditions were not provided. On 15-NOV-2012 the patient was vaccinated with a dose of ZOSTAVAX. Dose, route and lot number were not provided. No concomitant medications were reported. On an unknown date the patient experienced multi-organ failure and cardiac arrest. The outcome of multi-organ failure and cardiac arrest was reported as fatal. The patient died on 13-DEC-2012 at 1515 (military time) in the hospital. The cause of death was reported as cardiac arrest and multi-organ failure, according to the Death Certificate. No reporter causality was provided. Additional information has been requested. The following information was obtained through follow-up and/or provided by the government. 03/26/13 Hospital records, consultations, and discharge summary received. Service dates 12/11/12 to 12/13/12. Diagnosis: MCA Territory Stroke. Respiratory failure. Patient presents with chest pain, planning on heart catherization. Complaints of left arm and shoulder pain, nausea, shortness of breath. Unsucessful cardiac catherization. Non-ST-elevation MI, intra-aortic balloon pump placed in descending aorta and malfunctioned. Developed continuous twitching on right side with myoclonic jerking. Intubation, mechanical ventilation. Unresponsive. Deep tendon reflexes diminished. 8/1/13 Death Certificate received. Final Cause of Death: Multi Organ Failure. Other information abstracted: Cardiac arrest, Non-ST-Elevation Myocardial Infarction.


Changed on 6/14/2014

VAERS ID: 485686 Before After
VAERS Form:
Age:82.0
Sex:Male
Location:Colorado
Vaccinated:2012-11-15
Onset:0000-00-00
Submitted:2013-02-27
Entered:2013-02-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS - / - UN / UN
VARZOS: ZOSTER (ZOSTAVAX) / MERCK & CO. INC. - / 0 UN / UN

Administered by: Other      Purchased by: Other
Symptoms: Cardiac arrest, Death, Multi-organ failure

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-12-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: No other medications
Current Illness: Unknown
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': WAES1302USA012087

Write-up: This spontaneous report as received from a consumer refers to an 82 year old male patient. The patient''s medical history and concurrent conditions were not provided. On 15-NOV-2012 the patient was vaccinated with a dose of ZOSTAVAX. Dose, route and lot number were not provided. No concomitant medications were reported. On an unknown date the patient experienced multi-organ failure and cardiac arrest. The outcome of multi-organ failure and cardiac arrest was reported as fatal. The patient died on 13-DEC-2012 at 1515 (military time) in the hospital. The cause of death was reported as cardiac arrest and multi-organ failure, according to the Death Certificate. No reporter causality was provided. Additional information has been requested.


Changed on 3/14/2015

VAERS ID: 485686 Before After
VAERS Form:
Age:82.0
Sex:Male
Location:Colorado
Vaccinated:2012-11-15
Onset:0000-00-00
Submitted:2013-02-27
Entered:2013-02-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS - / - UN / UN
VARZOS: ZOSTER (ZOSTAVAX) / MERCK & CO. INC. - / 0 UN / UN

Administered by: Other      Purchased by: Other
Symptoms: Cardiac arrest, Death, Multi-organ failure

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-12-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: No other medications
Current Illness: Unknown
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': WAES1302USA012087

Write-up: This spontaneous report as received from a consumer refers to an 82 year old male patient. The patient''s medical history and concurrent conditions were not provided. On 15-NOV-2012 the patient was vaccinated with a dose of ZOSTAVAX. Dose, route and lot number were not provided. No concomitant medications were reported. On an unknown date the patient experienced multi-organ failure and cardiac arrest. The outcome of multi-organ failure and cardiac arrest was reported as fatal. The patient died on 13-DEC-2012 at 1515 (military time) in the hospital. The cause of death was reported as cardiac arrest and multi-organ failure, according to the Death Certificate. No reporter causality was provided. Additional information has been requested.


Changed on 9/14/2017

VAERS ID: 485686 Before After
VAERS Form:(blank) 1
Age:82.0
Sex:Male
Location:Colorado
Vaccinated:2012-11-15
Onset:0000-00-00
Submitted:2013-02-27
Entered:2013-02-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS - / - UNK UN / UN
VARZOS: ZOSTER (ZOSTAVAX) / MERCK & CO. INC. - / 0 1 UN / UN

Administered by: Other      Purchased by: Other
Symptoms: Cardiac arrest, Death, Multi-organ failure

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-12-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: No other medications
Current Illness: Unknown
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': WAES1302USA012087

Write-up: This spontaneous report as received from a consumer refers to an 82 year old male patient. The patient''s medical history and concurrent conditions were not provided. On 15-NOV-2012 the patient was vaccinated with a dose of ZOSTAVAX. Dose, route and lot number were not provided. No concomitant medications were reported. On an unknown date the patient experienced multi-organ failure and cardiac arrest. The outcome of multi-organ failure and cardiac arrest was reported as fatal. The patient died on 13-DEC-2012 at 1515 (military time) in the hospital. The cause of death was reported as cardiac arrest and multi-organ failure, according to the Death Certificate. No reporter causality was provided. Additional information has been requested.


Changed on 2/14/2018

VAERS ID: 485686 Before After
VAERS Form:1
Age:82.0
Sex:Male
Location:Colorado
Vaccinated:2012-11-15
Onset:0000-00-00
Submitted:2013-02-27
Entered:2013-02-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS - / UNK UN / UN
VARZOS: ZOSTER (ZOSTAVAX) / MERCK & CO. INC. - / 1 UN / UN

Administered by: Other      Purchased by: Other
Symptoms: Cardiac arrest, Death, Multi-organ failure

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-12-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: No other medications
Current Illness: Unknown
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': WAES1302USA012087

Write-up: This spontaneous report as received from a consumer refers to an 82 year old male patient. The patient''s medical history and concurrent conditions were not provided. On 15-NOV-2012 the patient was vaccinated with a dose of ZOSTAVAX. Dose, route and lot number were not provided. No concomitant medications were reported. On an unknown date the patient experienced multi-organ failure and cardiac arrest. The outcome of multi-organ failure and cardiac arrest was reported as fatal. The patient died on 13-DEC-2012 at 1515 (military time) in the hospital. The cause of death was reported as cardiac arrest and multi-organ failure, according to the Death Certificate. No reporter causality was provided. Additional information has been requested.


Changed on 6/14/2018

VAERS ID: 485686 Before After
VAERS Form:1
Age:82.0
Sex:Male
Location:Colorado
Vaccinated:2012-11-15
Onset:0000-00-00
Submitted:2013-02-27
Entered:2013-02-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS - / UNK UN / UN
VARZOS: ZOSTER (ZOSTAVAX) / MERCK & CO. INC. - / 1 UN / UN

Administered by: Other      Purchased by: Other
Symptoms: Cardiac arrest, Death, Multi-organ failure

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-12-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: No other medications
Current Illness: Unknown
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': WAES1302USA012087

Write-up: This spontaneous report as received from a consumer refers to an 82 year old male patient. The patient''s medical history and concurrent conditions were not provided. On 15-NOV-2012 the patient was vaccinated with a dose of ZOSTAVAX. Dose, route and lot number were not provided. No concomitant medications were reported. On an unknown date the patient experienced multi-organ failure and cardiac arrest. The outcome of multi-organ failure and cardiac arrest was reported as fatal. The patient died on 13-DEC-2012 at 1515 (military time) in the hospital. The cause of death was reported as cardiac arrest and multi-organ failure, according to the Death Certificate. No reporter causality was provided. Additional information has been requested.


Changed on 8/14/2018

VAERS ID: 485686 Before After
VAERS Form:1
Age:82.0
Sex:Male
Location:Colorado
Vaccinated:2012-11-15
Onset:0000-00-00
Submitted:2013-02-27
Entered:2013-02-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS - / UNK UN / UN
VARZOS: ZOSTER (ZOSTAVAX) / MERCK & CO. INC. - / 1 UN / UN

Administered by: Other      Purchased by: Other
Symptoms: Cardiac arrest, Death, Multi-organ failure

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-12-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: No other medications
Current Illness: Unknown
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': WAES1302USA012087

Write-up: This spontaneous report as received from a consumer refers to an 82 year old male patient. The patient''s medical history and concurrent conditions were not provided. On 15-NOV-2012 the patient was vaccinated with a dose of ZOSTAVAX. Dose, route and lot number were not provided. No concomitant medications were reported. On an unknown date the patient experienced multi-organ failure and cardiac arrest. The outcome of multi-organ failure and cardiac arrest was reported as fatal. The patient died on 13-DEC-2012 at 1515 (military time) in the hospital. The cause of death was reported as cardiac arrest and multi-organ failure, according to the Death Certificate. No reporter causality was provided. Additional information has been requested.


Changed on 9/14/2018

VAERS ID: 485686 Before After
VAERS Form:1
Age:82.0
Sex:Male
Location:Colorado
Vaccinated:2012-11-15
Onset:0000-00-00
Submitted:2013-02-27
Entered:2013-02-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS - / UNK UN / UN
VARZOS: ZOSTER (ZOSTAVAX) / MERCK & CO. INC. - / 1 UN / UN

Administered by: Other      Purchased by: Other
Symptoms: Cardiac arrest, Death, Multi-organ failure

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-12-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: No other medications
Current Illness: Unknown
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': WAES1302USA012087

Write-up: This spontaneous report as received from a consumer refers to an 82 year old male patient. The patient''s medical history and concurrent conditions were not provided. On 15-NOV-2012 the patient was vaccinated with a dose of ZOSTAVAX. Dose, route and lot number were not provided. No concomitant medications were reported. On an unknown date the patient experienced multi-organ failure and cardiac arrest. The outcome of multi-organ failure and cardiac arrest was reported as fatal. The patient died on 13-DEC-2012 at 1515 (military time) in the hospital. The cause of death was reported as cardiac arrest and multi-organ failure, according to the Death Certificate. No reporter causality was provided. Additional information has been requested.


Changed on 10/14/2018

VAERS ID: 485686 Before After
VAERS Form:1
Age:82.0
Sex:Male
Location:Colorado
Vaccinated:2012-11-15
Onset:0000-00-00
Submitted:2013-02-27
Entered:2013-02-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS - / UNK UN / UN
VARZOS: ZOSTER (ZOSTAVAX) / MERCK & CO. INC. - / 1 UN / UN

Administered by: Other      Purchased by: Other
Symptoms: Cardiac arrest, Death, Multi-organ failure

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-12-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: No other medications
Current Illness: Unknown
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': WAES1302USA012087

Write-up: This spontaneous report as received from a consumer refers to an 82 year old male patient. The patient''s medical history and concurrent conditions were not provided. On 15-NOV-2012 the patient was vaccinated with a dose of ZOSTAVAX. Dose, route and lot number were not provided. No concomitant medications were reported. On an unknown date the patient experienced multi-organ failure and cardiac arrest. The outcome of multi-organ failure and cardiac arrest was reported as fatal. The patient died on 13-DEC-2012 at 1515 (military time) in the hospital. The cause of death was reported as cardiac arrest and multi-organ failure, according to the Death Certificate. No reporter causality was provided. Additional information has been requested.


Changed on 8/14/2019

VAERS ID: 485686 Before After
VAERS Form:1
Age:82.0
Sex:Male
Location:Colorado
Vaccinated:2012-11-15
Onset:0000-00-00
Submitted:2013-02-27
Entered:2013-02-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS - / UNK UN / UN
VARZOS: ZOSTER (ZOSTAVAX) ZOSTER LIVE (ZOSTAVAX) / MERCK & CO. INC. - / 1 UN / UN

Administered by: Other      Purchased by: Other
Symptoms: Cardiac arrest, Death, Multi-organ failure

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-12-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: No other medications
Current Illness: Unknown
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': WAES1302USA012087

Write-up: This spontaneous report as received from a consumer refers to an 82 year old male patient. The patient''s medical history and concurrent conditions were not provided. On 15-NOV-2012 the patient was vaccinated with a dose of ZOSTAVAX. Dose, route and lot number were not provided. No concomitant medications were reported. On an unknown date the patient experienced multi-organ failure and cardiac arrest. The outcome of multi-organ failure and cardiac arrest was reported as fatal. The patient died on 13-DEC-2012 at 1515 (military time) in the hospital. The cause of death was reported as cardiac arrest and multi-organ failure, according to the Death Certificate. No reporter causality was provided. Additional information has been requested.

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