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From the 9/17/2013 release of VAERS data (an older release, current is 2/26/2021):

This is VAERS ID 485686

Case Details

VAERS ID: 485686 (history)  
Form: Version .0  
Age: 82.0  
Sex: Male  
Location: Colorado  
Submitted: 2013-02-27
Entered: 2013-02-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: Other
Symptoms: Acute myocardial infarction, Cardiac arrest, Death, Multi-organ failure
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Myocardial infarction (narrow), 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), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Tumour lysis syndrome (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 The following information was obtained through follow-up and/or provided by the government. 03/26/13 Valvular heart disease, hypertension chronic with renal disease, chronic stable congestive heart failure with dystolic dysfunction, chronic kidney disease stage III, hyperlipidemia, peripheral vascular disease with carotid disease and atherosclerosis, hyponatremia, mitral regurgitation.
Preexisting Conditions: The following information was obtained through follow-up and/or provided by the government. 03/26/13 PMH: Graves disease, prostate cancer with orchiectomy, atrial fibrillation, stroke, pacemaker, osteoporosis, gastric ulcer, hearing loss. Aortic valve replacement, partial colectomy, vagotomy.
Diagnostic Lab Data: The following information was obtained through follow-up and/or provided by the government. 03/26/13 Labs and Diagnostics: ECG - Abnormal. Chest X-ray - Abnormal. CT Brain - Abnormal. EEG - Abnormal.
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. The following information was obtained through follow-up and/or provided by the government. 03/26/13 Hospital records, consultations, and discharge summary received. Service dates 12/11/12 to 12/13/12. Diagnosis: MCA Territory Stroke. Respiratory failure. Patient presents with chest pain, planning on heart catherization. Complaints of left arm and shoulder pain, nausea, shortness of breath. Unsucessful cardiac catherization. Non-ST-elevation MI, intra-aortic balloon pump placed in descending aorta and malfunctioned. Developed continuous twitching on right side with myoclonic jerking. Intubation, mechanical ventilation. Unresponsive. Deep tendon reflexes diminished. 8/1/13 Death Certificate received. Final Cause of Death: Multi Organ Failure. Other information abstracted: Cardiac arrest, Non-ST-Elevation Myocardial Infarction.

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