| VAERS ID: |
26837 (history) |
| Form: |
Version .0 |
| Age: |
79.8 |
| Sex: |
Female |
| Location: |
Colorado |
| Vaccinated: | 1990-10-25 |
| Onset: | 1990-11-01 |
| Days after vaccination: | 7 |
| Submitted: |
1990-11-15 |
| Days after onset: | 14 |
| Entered: |
1990-11-28 |
| Days after submission: | 13 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| FLU: INFLUENZA (SEASONAL) (NO BRAND NAME, 90-91) / WYETH PHARMACEUTICALS, INC |
- / - |
- / IM |
Administered by: Private Purchased by: Private
Symptoms: Gastrointestinal haemorrhage,
Pain,
Pleural effusion,
Rash,
Splenomegaly,
Vasculitis,
Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Systemic lupus erythematosus (broad), Gastrointestinal haemorrhage (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Ischaemic colitis (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Vasculitis (narrow)
Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 10 days
Extended hospital stay? No
Previous Vaccinations: Vasculitis 1 wk /p previous vax of Influenza 89-90 formula
Other Medications: Synthroid, Aldactazide
Current Illness: none
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: 890311001B
Write-up: Pt vaccinated with Influenza developed vasculitis described as severe rash on her arms & legs. Also experienced pain & vomiting. |
