Adverse Event Reporting
| VAERS ID | 2032366 |
|---|---|
| Gender | Male |
| Age | 73 |
| StateCode | IL |
| Pharmaceutical Company | PFIZER\BIONTECH |
| Lot Number | EM9809 |
| Number of vaccinations | 2 |
| Vaccinated | 2021-04-13 |
| Onset | 2021-08-29 |
| Condition | Hospitalized Died |
Symptoms
- Dyspnoea
- Decreased appetite
- SARS-CoV-2 test positive
- COVID-19
- Exposure to SARS-CoV-2
- Pneumonia
- Acute kidney injury
- COVID-19 pneumonia
- Death
- Leukocytosis
- Culture wound positive
- Fungal infection
- Agonal respiration
- Vaccine breakthrough infection
- Positive airway pressure therapy
- Fluid balance positive
Current Illness
CAD HTN DM Type 2 Pancreatic cancer
Preexisting Conditions
CAD HTN DM Type 2 Pancreatic cancer
Other Medications
apixaban 5 mg PO QD aspirin 81 mg PO QD vitamin D 1000 units PO QD clopidogrel 75 mg PO QD furosemide 40 mg PO BID levothyroxine 100 mcg PO QD magnesium gluconate 500 mg PO QD metformin 1000 mg PO QPM metformin 500 mg PO QAM metoprolol ER 5
Previous Vaccinations
Allergies
NKDA
Laboratory Data
see above
Write-up
COVID Vaccine Breakthrough Case Pfizer Dose 1 3/23/21 (EN6204) Pfizer Dose 2 4/13/21 (EM9809) COVID Positive 9/1/21 9/1/21: 73-year-old male with a past medical history of CHF, CAD, recurrent left pulmonary effusions, pancreatic cancer status post Whipple procedure presents with worsening shortness of breath.
Of note patient was recently hospitalized for similar issues.
Patient says after discharge he was feeling fine but started to developed shortness of breath and decreased appetite over the last 3 days.
Spoke to patient's daughter who stated that the patient had not been following dietary restrictions and had not been moving around much since discharge.
VNA Services did check with the patient after discharge.
Patient had been exposed to COVID during this entire time.
In the ED the patient had a positive COVID test and imaging showed bilateral pneumonia.
Patient will be admitted for evaluation of COVID.
9/11/21: Patient was admitted on September 1, 2021 for evaluation of bilateral COVID pneumonia.
Patient received a full course of remdesivir, 5 days of Decadron, 7 days of azithromycin and Rocephin.
Initially the patient was maintaining moderate oxygen supplementation starting at 3 L and was titrated down to 1 L.
On the evening of day 6, the patient began to require additional oxygen supplementation and by day 7 the patient was requiring BiPAP.
Cardiology was consulted on day 5 and recommendations were to try to titrate Lasix down as the patient was improving at that time.
Due to a developing positive fluid balance Lasix was increased.
Nephrology was consulted on day 9 for worsening AKI and recommended that the patient may need hemodialysis in the near future.
Pulmonology was contacted and updated throughout the entire hospitalization and was formally consulted on day 10 and recommended that due to the patient's poor prognosis, against intubation and initiation of comfort care.
On day 9 the patient was made DNR with intubation.
Facility was contacted on day 10 due to the family's request and declined a transfer request.
On day 10 the patient was started on Zosyn and Diflucan due to worsening leukocytosis and a wound culture taken during the hospitalization was positive for yeast; Infectious Disease was not available for consult the during this day.
On day 11 the patient was noticed to have agonal breathing and the patient's daughter was contacted and made wishes for the patient to be a full DNR/DNI.
The patient was pronounced dead on September 11, 2021 at 10:45 a.
m.