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From the 4/13/2011 release of VAERS data (an older release, current is 1/7/2022):

This is VAERS ID 414974

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Case Details

VAERS ID: 414974 (history)  
Form: Version .0  
Age: 76.0  
Sex: Male  
Location: Illinois  
   Days after vaccination:95
Submitted: 2011-01-19
   Days after onset:24
Entered: 2011-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: Private
Symptoms: Acute myocardial infarction, Acute prerenal failure, Acute respiratory failure, Anaemia, Antibiotic resistant Staphylococcus test positive, Anxiety, Areflexia, Ascites, Blood culture positive, CSF culture negative, CSF glucose increased, CSF protein normal, Cardiogenic shock, Cardiomegaly, Chest X-ray abnormal, Chest pain, Cholelithiasis, Death, Diarrhoea, Dyspnoea, Echocardiogram abnormal, Electrocardiogram ST segment elevation, Electrocardiogram abnormal, Endotracheal intubation, Extubation, Gallbladder disorder, Gastrointestinal tube insertion, Guillain-Barre syndrome, Hyponatraemia, Hypophosphataemia, Hypotension, Immunoglobulin therapy, Intensive care, Klebsiella infection, Left atrial dilatation, Left ventricular hypertrophy, Liver function test abnormal, Lumbar puncture, Malaise, Mechanical ventilation, Multi-organ failure, Muscular weakness, Myocardial infarction, Nausea, Nuclear magnetic resonance imaging spinal cord abnormal, Osteoarthritis, Pericardial effusion, Plasmapheresis, Pleural effusion, Pyrexia, Sepsis, Septic shock, Splenomegaly, Sputum culture positive, Ultrasound abdomen abnormal, Vomiting
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Liver related investigations, signs and symptoms (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Agranulocytosis (broad), Angioedema (broad), Haematopoietic erythropenia (broad), Peripheral neuropathy (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (narrow), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Pseudomembranous colitis (broad), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (narrow), Gallbladder related disorders (narrow), Gallstone related disorders (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (narrow), Noninfectious encephalopathy/delirium (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hyponatraemia/SIADH (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Demyelination (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2011-01-06
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, 11 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: none
Preexisting Conditions: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Per patients daughter, he developed Guillain Barre Syndrome. He fell ill on 12/26/2010, was admitted to Medical Center and passed away on 1/6/2011.

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