National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

This is VAERS ID 485686

(NOTE: This result is from the 5/13/2013 version of the VAERS database)

Case Details

VAERS ID: 485686 (history)  
Form: Version .0  
Age: 82.0  
Sex: Male  
Location: Colorado  
Vaccinated:2012-11-15
Onset:0000-00-00
Submitted: 2013-02-27
Entered: 2013-02-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS - / - UN / UN
VARZOS: ZOSTER (ZOSTAVAX) / MERCK & CO. INC. - / 0 UN / UN

Administered by: Other       Purchased by: Other
Symptoms: Cardiac arrest, Death, Multi-organ failure
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (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 (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2012-12-13
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: No other medications
Current Illness: Unknown
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: WAES1302USA012087

Write-up: This spontaneous report as received from a consumer refers to an 82 year old male patient. The patient''s medical history and concurrent conditions were not provided. On 15-NOV-2012 the patient was vaccinated with a dose of ZOSTAVAX. Dose, route and lot number were not provided. No concomitant medications were reported. On an unknown date the patient experienced multi-organ failure and cardiac arrest. The outcome of multi-organ failure and cardiac arrest was reported as fatal. The patient died on 13-DEC-2012 at 1515 (military time) in the hospital. The cause of death was reported as cardiac arrest and multi-organ failure, according to the Death Certificate. No reporter causality was provided. Additional information has been requested.


New Search

Link To This Search Result:

https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20130513&IDNUMBER=485686


Copyright © 2020 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166