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From the 12/31/2003 release of VAERS data (an older release, current is 10/15/2021):

This is VAERS ID 27639

Case Details

VAERS ID: 27639 (history)  
Form: Version .0  
Sex: Female  
Location: Tennessee  
Submitted: 1990-12-26
Entered: 1991-02-01
   Days after submission:37
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: FLU-IMUNE 1990-1991 LEDERLE / LEDERLE - / - - / -

Administered by: Other       Purchased by: Unknown

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? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Bronchiectasis
Diagnostic Lab Data:
CDC Split Type:

Write-up: 4-5 hrs after receiving Influenza vaccine, pt experienced respiratory distress & fever of 105. Hospitalized for 3 days.

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