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This is VAERS ID 63043

Case Details

VAERS ID: 63043 (history)  
Form: Version 1.0  
Age: 64.0  
Sex: Male  
Location: Mississippi  
Vaccinated:1993-10-14
Onset:1993-10-21
   Days after vaccination:7
Submitted: 1994-05-17
   Days after onset:208
Entered: 1994-05-23
   Days after submission:6
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 3F41016 / 1 - / A

Administered by: Unknown       Purchased by: Public
Symptoms: Infection, Pyrexia, Thrombosis, Vasculitis
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad), Vasculitis (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
   Extended hospital stay? Yes
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt recvd flu vax & 6 days later was real ill from then until 5MAR t100-103.5 24 hrs day; went into hosp 15NOV93; ATB for 40 days; temp cont; hosp 16FEB-26; vasculitis from virus; 4MAY blood clot; no sx of cold or illness until took flu shot


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