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This is VAERS ID 94662

Case Details

VAERS ID: 94662 (history)  
Form: Version 1.0  
Age: 43.0  
Sex: Male  
Location: South Carolina  
Vaccinated:1996-12-20
Onset:1996-12-20
   Days after vaccination:0
Submitted: 1996-12-31
   Days after onset:11
Entered: 1997-02-06
   Days after submission:37
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 6F71316 / 2 - / IM

Administered by: Public       Purchased by: Public
Symptoms: Back pain, Chest pain, Dyspnoea, Hyperhidrosis, Hypotension, Myocarditis, Pallor, Pericarditis
SMQs:, Anaphylactic reaction (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Retroperitoneal fibrosis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-12-20
   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: NONE
Preexisting Conditions: asthma
Allergies:
Diagnostic Lab Data: unk
CDC Split Type: SC96071

Write-up: pt recv vax 20DEC96 1230PM & pt became pale, sweating profusely & was in pain (both chest & jaw) & SOB;EMS transported pt to local hosp ER:BP was 1/2 nl 90/50;died 830PM;


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