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From the 9/17/2021 release of VAERS data:

This is VAERS ID 612778



Case Details

VAERS ID: 612778 (history)  
Form: Version 1.0  
Age: 12.0  
Sex: Male  
Location: Nevada  
Vaccinated:2015-11-16
Onset:2015-11-16
   Days after vaccination:0
Submitted: 2015-12-01
   Days after onset:15
Entered: 2015-12-02
   Days after submission:1
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLUX: INFLUENZA (SEASONAL) (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK LA / UN
HPVX: HPV (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK RA / UN
MENB: MENINGOCOCCAL B (TRUMENBA) / PFIZER/WYETH - / UNK LA / IM

Administered by: Private       Purchased by: Other
Symptoms: Bradycardia, Confusional state, Pallor, Speech disorder, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Dementia (broad), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: No other medications
Current Illness: None
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: 2015400986

Write-up: This is a spontaneous report obtained from a contactable physician through a Pfizer sales representative. A 12-year-old male patient received, on 16Nov2015, TRUMENBA intramuscular, in the left deltoid, at 0.5 ml, single dose. Relevant medical history was unknown. Concomitant medications included flu vaccine received in the left deltoid and HPV vaccine received in the right deltoid, both on 16Nov2015. The vaccines were administered at the private doctor''s office and was purchased with commercial funds. On 16Nov2015, the patient was pale, had bradycardia, and fainted in office. On the same evening, family reported the patient was confused and was talking gibberish. No hospitalization, emergency room or doctor visit were required. Clinical outcome was unknown at time of this report.


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