VAERS ID: |
61058 (history) |
Form: |
Version 1.0 |
Age: |
69.0 |
Sex: |
Female |
Location: |
New York |
Vaccinated: | 1992-10-12 |
Onset: | 1992-11-12 |
Days after vaccination: | 31 |
Submitted: |
1994-03-09 |
Days after onset: | 482 |
Entered: |
1994-03-28 |
Days after submission: | 19 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
FLU3: INFLUENZA (SEASONAL) (FLU-IMUNE) / PFIZER/WYETH |
337916 / 1 |
- / A |
Administered by: Private Purchased by: Private Symptoms: Apnoea,
Cardiac failure,
Neck pain,
Neuropathy,
Nuchal rigidity,
Peroneal nerve palsy,
Pruritus,
Speech disorder SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Peripheral neuropathy (narrow), Dementia (broad), Acute central respiratory depression (narrow), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Arthritis (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)
Life Threatening? Yes
Birth Defect? No
Died? Yes
Date died: 0000-00-00
Permanent Disability? Yes
Recovered? No Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, 7 days
Extended hospital stay? No
Previous Vaccinations: ~ ()~~~In patient Other Medications: NONE Current Illness: NONE Preexisting Conditions: NONE Allergies: Diagnostic Lab Data: EMG, 14MAY93; EMG log #93-463; CDC Split Type:
Write-up: approx 1 month p/flu vax, painful stiff neck, pain lt leg, lt foot drop; neurological tests indicated neuro disease; spinal tap hos dx A-myotrophic lateral sceloris (ALS); JUL93 lt side nerve degeneration & speech affected; also devel itch |