| VAERS ID: |
59156 (history) |
| Form: |
Version 1.0 |
| Age: |
78.0 |
| Sex: |
Male |
| Location: |
California |
| Vaccinated: | 1993-10-01 |
| Onset: | 1993-10-01 |
| Days after vaccination: | 0 |
| Submitted: |
1994-01-04 |
| Days after onset: | 95 |
| Entered: |
1994-01-18 |
| Days after submission: | 14 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES |
3F41142 / UNK |
- / - |
Administered by: Unknown Purchased by: Unknown
Symptoms: Apnoea,
Atrioventricular block complete,
Guillain-Barre syndrome,
Pneumonia,
Respiratory disorder,
Sepsis
SMQs:, Peripheral neuropathy (narrow), Conduction defects (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (narrow), Demyelination (narrow), Eosinophilic pneumonia (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (narrow)
Life Threatening? Yes
Birth Defect? No
Died? Yes
Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
Extended hospital stay? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness:
Preexisting Conditions: Ocular Myasthenia Gravis (only Ocular); DIabetes; hypertension;
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: pt was given flu vax 1OCT93 & w/in 1 wk devel sx of GBS w/resp failure requiring ventilator support & 3 heart blocks requiring pacemaker; pt devel complication of pneumonia later on ventilator & died secondary to sepsis w/in wks; |
