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From the 5/7/2021 release of VAERS data:

This is VAERS ID 854704



Case Details

VAERS ID: 854704 (history)  
Form: Version 2.0  
Age: 103.0  
Sex: Female  
Location: Foreign  
Vaccinated:2019-11-15
Onset:2019-11-19
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2019-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLUA3: INFLUENZA (SEASONAL) (FLUAD) / NOVARTIS VACCINES AND DIAGNOSTICS A031840034 / UNK - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Aphasia, Asthenia, Cerebrovascular accident, Death, Decreased appetite, Presyncope
SMQs:, Anticholinergic syndrome (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2019-11-26
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: TRIATEC [RAMIPRIL]; CARDIOASPIRIN; LANSOPRAZOLE; ZYLORIC; LASIX [FUROSEMIDE SODIUM]
Current Illness: Cardiomyopathy; Decompensation cardiac
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: ITSEQIRUS201907433

Write-up: Suspected cerebral stroke; Inappetence; Aphasia; Asthenia; Presyncope; This is a spontaneous cas, reported by physician to Agency (reference number: IT-MINISAL02-594481) and initially retrieved on 23-Dec-2019 with additional information (being processed together) retrieved on 24-Dec-2019, concerning a 103-year-old, female patient. The patient''s current condition included cardiac decompensation and cardiomyopathy. The patient''s concomitant medications included Triatec (ramipril), Cardioaspirin (acetylsalicylic acid), Zyloric (allopurinol), Lasix (furosemide sodium) and lansoprazole, all for an unknown indication. On 15-Nov-2019, the patient was administered Fluad (TIV) [influenza vaccine, inactivated influenza virus surface antigen (subunit), egg-derived, MF59; batch number: A031840034; dose reported as one dosage form; route of administration: intramuscular; anatomical location and expiry date: not reported] as flu vaccination. On 19-Nov-2019, four days after vaccination, it was suspected that the patient experienced cerebral stroke. The patient also experienced aphasia, inappetence, asthenia and presyncope. On an unknown date in Nov-2019, the patient had slight recovery of her state. On 24-Nov-2019, the patient experienced new worsening. On 26-Nov-2019, the patient died. It was unknown if autopsy was done. The events of inappetence, aphasia, asthenia, presyncope and stroke were considered serious due to fatal outcome. The reporter did not provide causality assessment. Company comment: All events are considered as related to Fluad (TIV).; Sender''s Comments: All events are considered as related to Fluad (TIV).; Reported Cause(s) of Death: Suspected cerebral stroke; Inappetence; Aphasia; Asthenia; Presyncope


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