| VAERS ID: |
90265 (history) |
| Form: |
Version 1.0 |
| Age: |
52.0 |
| Sex: |
Male |
| Location: |
California |
| Vaccinated: | 1996-09-18 |
| Onset: | 1996-09-22 |
| Days after vaccination: | 4 |
| Submitted: |
1996-09-27 |
| Days after onset: | 5 |
| Entered: |
1996-09-30 |
| Days after submission: | 3 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| FLUX: INFLUENZA (SEASONAL) (NO BRAND NAME) / UNKNOWN MANUFACTURER |
6F71223 / UNK |
- / - |
Administered by: Private Purchased by: Private
Symptoms: Anaphylactoid reaction,
Asphyxia,
Hypersensitivity,
Influenza,
Laryngeal oedema
SMQs:, Anaphylactic reaction (narrow), Angioedema (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Acute central respiratory depression (broad), Hostility/aggression (broad), Hypersensitivity (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 1996-09-22
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: CO6786
Write-up: death, flu-like sx 3 days p/shot; |
