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This is VAERS ID 27412

(NOTE: This result is from the 9/14/2018 version of the VAERS database)

Case Details

VAERS ID: 27412 (history)  
Form: Version 1.0  
Age: 30.0  
Sex: Male  
Location: Washington  
Vaccinated:1990-12-31
Onset:1991-01-02
   Days after vaccination:2
Submitted: 1991-01-03
   Days after onset:1
Entered: 1991-01-14
   Days after submission:11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 0F11223 / 1 LA / IM

Administered by: Public       Purchased by: Public
Symptoms: Diarrhoea, Headache, Hyperhidrosis, Myalgia, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Pseudomembranous colitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Noninfectious diarrhoea (narrow), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness:
Preexisting Conditions: hx asthma
Allergies:
Diagnostic Lab Data:
CDC Split Type: WA91503

Write-up: Approx 40 min after immun developed cold sweats, blacked out upon arising; headache x 12 hrs; muscle ached, diarrhea, temp 97.0.


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