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From the 4/30/2021 release of VAERS data:

This is VAERS ID 795791



Case Details

VAERS ID: 795791 (history)  
Form: Version 2.0  
Age: 0.75  
Sex: Male  
Location: South Carolina  
Vaccinated:2019-01-10
Onset:2019-01-10
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2019-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU4: INFLUENZA (SEASONAL) (FLUZONE QUADRIVALENT) / SANOFI PASTEUR UT6259MA / 1 LL / IM

Administered by: Private       Purchased by: ?
Symptoms: Blood glucose, Body temperature decreased, Cardiac arrest, Cyanosis, Death, Endotracheal intubation, Resuscitation, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Angioedema (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2019-01-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None known
Current Illness: Upper respiratory illness
Preexisting Conditions: None
Allergies: None known
Diagnostic Lab Data: Blood glucose noted in ED record
CDC Split Type:

Write-up: Per ER report, patient received his Flu vaccine at his 9 month well check. Parents took him home. He fed and then went down for a nap. One to two hours later mother reports finding the child cyanotic and unresponsive. EMS called and found him in asystole. EMS attempted resuscitation en route to ER by placing IO and attempted intubation. He was given epinephrine x 2. CPR continued in the ED. Warmed to 35.4, intubated with 3.5 cuffed ET and received multiple rounds of epinephrine. Chest compressions were recorded for 18 minutes. Time of death was called at 1814.


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