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From the 1/7/2022 release of VAERS data:

This is VAERS ID 105297

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Case Details

VAERS ID: 105297 (history)  
Form: Version 1.0  
Age: 0.4  
Sex: Male  
Location: California  
Vaccinated:1997-09-08
Onset:1997-09-08
   Days after vaccination:0
Submitted: 1997-10-28
   Days after onset:50
Entered: 1997-12-02
   Days after submission:35
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 447788 / UNK LL / -
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 2352A / UNK RL / -
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. M1070 / UNK RL / -

Administered by: Private       Purchased by: Other
Symptoms: Cardiac arrest, Cyanosis, Dyspnoea, Encephalopathy, Infection, Pneumonia, Retinal haemorrhage, Sudden infant death syndrome
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Retinal disorders (narrow), Neonatal disorders (narrow), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1997-10-04
   Days after onset: 26
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: fever 104.0 all day;1AM 9SEp went to hosp for fever given motrin sent home;9SEP started coughing @ hosp;went to primary MD on 10SEP & was wheezing & coughing recvd albuterol tx in office;wheezed until 3OCT;redness & knots on legs p/vax


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