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This is VAERS ID 120450

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 120450
VAERS Form:
Age:1.0
Sex:Female
Location:Alabama
Vaccinated:1999-03-10
Onset:1999-03-13
Submitted:1999-03-18
Entered:1999-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: INFANRIX / SMITHKLINE 865A2 / 2 LL / IM
HIBV: HIBTITER / LEDERLE(PRAXIS) 361453 / 2 RL / IM
MMR: MMR II / MSD 0734E / 0 LL / SC
OPV: ORIMUNE / LEDERLE 79413 / 2 - / PO
VARCEL: VARIVAX / MSD 10524 / 0 LA / SC

Administered by: Public      Purchased by: Unknown
Symptoms: FEVER, APNEA, HEART ARREST, BRONCHIOLITIS, HEM VAGINAL

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1999-03-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: lt lung culture:Viridans Streptococcus, 2 colonies Candida, Haemophilus, beta lactamase+; rt lung culture: haemophilus, beta lactamase+; Blood culture: Staphylococcus epidermidis; 6/99 tissue block recv for analysis;
CDC 'Split Type':

Write-up: pt expired 3 days p/vax;pt arrived in ER in full arrest where pt died pt had been sick w/fever & vomiting during night;autopsy dx viral myocarditis w/ superimposed bacterial pneumonia, per examiner myocarditis probably dated prior to vax


Changed on 12/8/2009

VAERS ID: 120450 Before After
VAERS Form:
Age:1.0
Sex:Female
Location:Alabama
Vaccinated:1999-03-10
Onset:1999-03-13
Submitted:1999-03-18
Entered:1999-03-23 1999-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: INFANRIX DTAP (INFANRIX) / SMITHKLINE SMITHKLINE BEECHAM 865A2 / 2 LL / IM
HIBV: HIBTITER HIB (HIBTITER) / LEDERLE(PRAXIS) LEDERLE PRAXSIS 361453 / 2 RL / IM
MMR: MMR II MEASLES + MUMPS + RUBELLA (MMR II) / MSD MERCK & CO. INC. 0734E / 0 LL / SC
OPV: ORIMUNE POLIO VIRUS, ORAL (ORIMUNE) / LEDERLE LEDERLE LABORATORIES 79413 / 2 - / PO
VARCEL: VARIVAX VARICELLA (VARIVAX) / MSD MERCK & CO. INC. 10524 / 0 LA / SC

Administered by: Public      Purchased by: Unknown Public
Symptoms: Apnoea, Bronchiolitis, Cardiac arrest, Hepatomegaly, Laboratory test abnormal, Lymphadenopathy, Myocarditis, Neoplasm, Pneumonia, Pyrexia, Splenomegaly, Vaginal haemorrhage, Vomiting, FEVER, APNEA, HEART ARREST, BRONCHIOLITIS, HEM VAGINAL

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1999-03-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: lt lung culture:Viridans Streptococcus, 2 colonies Candida, Haemophilus, beta lactamase+; rt lung culture: haemophilus, beta lactamase+; Blood culture: Staphylococcus epidermidis; 6/99 tissue block recv for analysis;
CDC 'Split Type': (blank) WAES99032048

Write-up: pt expired 3 days p/vax;pt arrived in ER in full arrest where pt died pt had been sick w/fever & vomiting during night;autopsy dx viral myocarditis w/ superimposed bacterial pneumonia, per examiner myocarditis probably dated prior to vax


Changed on 5/14/2017

VAERS ID: 120450 Before After
VAERS Form:
Age:1.0
Sex:Female
Location:Alabama
Vaccinated:1999-03-10
Onset:1999-03-13
Submitted:1999-03-18
Entered:1999-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 865A2 / 2 LL / IM
HIBV: HIB (HIBTITER) / LEDERLE PRAXSIS PFIZER/WYETH 361453 / 2 RL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0734E / 0 LL / SC
OPV: POLIO VIRUS, ORAL (ORIMUNE) / LEDERLE LABORATORIES PFIZER/WYETH 79413 / 2 - / PO
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 10524 / 0 LA / SC

Administered by: Public      Purchased by: Public
Symptoms: Apnoea, Bronchiolitis, Cardiac arrest, Hepatomegaly, Laboratory test abnormal, Lymphadenopathy, Myocarditis, Neoplasm, Pneumonia, Pyrexia, Splenomegaly, Vaginal haemorrhage, Vomiting

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1999-03-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: none NONE
Preexisting Conditions: none NONE
Allergies:
Diagnostic Lab Data: lt lung culture:Viridans Streptococcus, 2 colonies Candida, Haemophilus, beta lactamase+; rt lung culture: haemophilus, beta lactamase+; Blood culture: Staphylococcus epidermidis; 6/99 tissue block recv for analysis; epidermidis
CDC 'Split Type': WAES99032048 AL9904

Write-up: hx of pt expired 3 days p/vax;pt arrived arriving in ER in full arrest where pt died pt had been sick w/fever & vomiting during night;autopsy dx viral myocarditis w/ superimposed bacterial pneumonia, per examiner myocarditis probably dated prior to vax expired @ hosp;sl bloody vaginal discharge noted in ER;


Changed on 9/14/2017

VAERS ID: 120450 Before After
VAERS Form:(blank) 1
Age:1.0
Sex:Female
Location:Alabama
Vaccinated:1999-03-10
Onset:1999-03-13
Submitted:1999-03-18
Entered:1999-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 865A2 / 2 3 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 361453 / 2 3 RL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0734E / 0 1 LL / SC
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 79413 / 2 3 - MO / PO
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 10524 / 0 1 LA / SC

Administered by: Public      Purchased by: Public
Symptoms: Apnoea, Bronchiolitis, Cardiac arrest, Hepatomegaly, Laboratory test abnormal, Lymphadenopathy, Myocarditis, Neoplasm, Pneumonia, Pyrexia, Splenomegaly, Vaginal haemorrhage, Vomiting

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1999-03-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: lt lung culture:Viridans Streptococcus, 2 colonies Candida, Haemophilus, beta lactamase+; rt lung culture: haemophilus, beta lactamase+; Blood culture: Staphylococcus epidermidis
CDC 'Split Type': AL9904

Write-up: hx of pt arriving in ER in full arrest & expired @ hosp;sl bloody vaginal discharge noted in ER;


Changed on 2/14/2018

VAERS ID: 120450 Before After
VAERS Form:1
Age:1.0
Sex:Female
Location:Alabama
Vaccinated:1999-03-10
Onset:1999-03-13
Submitted:1999-03-18
Entered:1999-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 865A2 / 3 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 361453 / 3 RL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0734E / 1 LL / SC
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 79413 / 3 MO / PO
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 10524 / 1 LA / SC

Administered by: Public      Purchased by: Public
Symptoms: Apnoea, Bronchiolitis, Cardiac arrest, Hepatomegaly, Laboratory test abnormal, Lymphadenopathy, Myocarditis, Neoplasm, Pneumonia, Pyrexia, Splenomegaly, Vaginal haemorrhage, Vomiting

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1999-03-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: lt lung culture:Viridans Streptococcus, 2 colonies Candida, Haemophilus, beta lactamase+; rt lung culture: haemophilus, beta lactamase+; Blood culture: Staphylococcus epidermidis
CDC 'Split Type': AL9904

Write-up: hx of pt arriving in ER in full arrest & expired @ hosp;sl bloody vaginal discharge noted in ER;


Changed on 6/14/2018

VAERS ID: 120450 Before After
VAERS Form:1
Age:1.0
Sex:Female
Location:Alabama
Vaccinated:1999-03-10
Onset:1999-03-13
Submitted:1999-03-18
Entered:1999-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 865A2 / 3 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 361453 / 3 RL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0734E / 1 LL / SC
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 79413 / 3 MO / PO
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 10524 / 1 LA / SC

Administered by: Public      Purchased by: Public
Symptoms: Apnoea, Bronchiolitis, Cardiac arrest, Hepatomegaly, Laboratory test abnormal, Lymphadenopathy, Myocarditis, Neoplasm, Pneumonia, Pyrexia, Splenomegaly, Vaginal haemorrhage, Vomiting

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1999-03-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: lt lung culture:Viridans Streptococcus, 2 colonies Candida, Haemophilus, beta lactamase+; rt lung culture: haemophilus, beta lactamase+; Blood culture: Staphylococcus epidermidis
CDC 'Split Type': AL9904

Write-up: hx of pt arriving in ER in full arrest & expired @ hosp;sl bloody vaginal discharge noted in ER;


Changed on 8/14/2018

VAERS ID: 120450 Before After
VAERS Form:1
Age:1.0
Sex:Female
Location:Alabama
Vaccinated:1999-03-10
Onset:1999-03-13
Submitted:1999-03-18
Entered:1999-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 865A2 / 3 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 361453 / 3 RL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0734E / 1 LL / SC
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 79413 / 3 MO / PO
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 10524 / 1 LA / SC

Administered by: Public      Purchased by: Public
Symptoms: Apnoea, Bronchiolitis, Cardiac arrest, Hepatomegaly, Laboratory test abnormal, Lymphadenopathy, Myocarditis, Neoplasm, Pneumonia, Pyrexia, Splenomegaly, Vaginal haemorrhage, Vomiting

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1999-03-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: lt lung culture:Viridans Streptococcus, 2 colonies Candida, Haemophilus, beta lactamase+; rt lung culture: haemophilus, beta lactamase+; Blood culture: Staphylococcus epidermidis
CDC 'Split Type': AL9904

Write-up: hx of pt arriving in ER in full arrest & expired @ hosp;sl bloody vaginal discharge noted in ER;


Changed on 9/14/2018

VAERS ID: 120450 Before After
VAERS Form:1
Age:1.0
Sex:Female
Location:Alabama
Vaccinated:1999-03-10
Onset:1999-03-13
Submitted:1999-03-18
Entered:1999-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 865A2 / 3 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 361453 / 3 RL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0734E / 1 LL / SC
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 79413 / 3 MO / PO
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 10524 / 1 LA / SC

Administered by: Public      Purchased by: Public
Symptoms: Apnoea, Bronchiolitis, Cardiac arrest, Hepatomegaly, Laboratory test abnormal, Lymphadenopathy, Myocarditis, Neoplasm, Pneumonia, Pyrexia, Splenomegaly, Vaginal haemorrhage, Vomiting

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1999-03-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: lt lung culture:Viridans Streptococcus, 2 colonies Candida, Haemophilus, beta lactamase+; rt lung culture: haemophilus, beta lactamase+; Blood culture: Staphylococcus epidermidis
CDC 'Split Type': AL9904

Write-up: hx of pt arriving in ER in full arrest & expired @ hosp;sl bloody vaginal discharge noted in ER;


Changed on 10/14/2018

VAERS ID: 120450 Before After
VAERS Form:1
Age:1.0
Sex:Female
Location:Alabama
Vaccinated:1999-03-10
Onset:1999-03-13
Submitted:1999-03-18
Entered:1999-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 865A2 / 3 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 361453 / 3 RL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0734E / 1 LL / SC
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 79413 / 3 MO / PO
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 10524 / 1 LA / SC

Administered by: Public      Purchased by: Public
Symptoms: Apnoea, Bronchiolitis, Cardiac arrest, Hepatomegaly, Laboratory test abnormal, Lymphadenopathy, Myocarditis, Neoplasm, Pneumonia, Pyrexia, Splenomegaly, Vaginal haemorrhage, Vomiting

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1999-03-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: lt lung culture:Viridans Streptococcus, 2 colonies Candida, Haemophilus, beta lactamase+; rt lung culture: haemophilus, beta lactamase+; Blood culture: Staphylococcus epidermidis
CDC 'Split Type': AL9904

Write-up: hx of pt arriving in ER in full arrest & expired @ hosp;sl bloody vaginal discharge noted in ER;

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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=120450&WAYBACKHISTORY=ON


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