| VAERS ID: |
110547 (history) |
| Form: |
Version 1.0 |
| Age: |
74.0 |
| Sex: |
Male |
| Location: |
Michigan |
| Vaccinated: | 1998-04-07 |
| Onset: | 1998-04-07 |
| Days after vaccination: | 0 |
| Submitted: |
1998-04-08 |
| Days after onset: | 1 |
| Entered: |
1998-05-04 |
| Days after submission: | 26 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| TD: TD ADSORBED (NO BRAND NAME) / CONNAUGHT LABORATORIES |
0923910 / 3 |
LA / IM |
Administered by: Private Purchased by: Private
Symptoms: Apnoea,
Cardiac arrest,
Coma,
Syncope,
Ventricular fibrillation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow), Hypoglycaemia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 1998-04-07
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: Azulfidine, HCTZ, Cardizem, Synthroid;
Current Illness: NONE
Preexisting Conditions: ulcerative colitis, asthma, CAD;
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: (null). The medical records state loss of consciousness and ventricular fibrillation. |
