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From the 1/14/2022 release of VAERS data:

This is VAERS ID 126221

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Case Details

VAERS ID: 126221 (history)  
Form: Version 1.0  
Age: 0.4  
Sex: Female  
Location: Minnesota  
Vaccinated:1999-02-18
Onset:1999-02-23
   Days after vaccination:5
Submitted: 1999-07-16
   Days after onset:142
Entered: 1999-07-21
   Days after submission:5
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 458588 / 1 LL / IM
HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC. 1616H / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. W08252 / 1 LA / SC
RV: ROTAVIRUS (ROTASHIELD) / PFIZER/WYETH 4988055 / 1 MO / PO

Administered by: Private       Purchased by: Private
Symptoms: Apnoea, Cardiac arrest, Gastroenteritis, Gastrointestinal haemorrhage, Gastrointestinal necrosis, Infection, Pharyngitis, Sepsis, Shock
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Agranulocytosis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Hypovolaemic shock conditions (narrow), Toxic-septic shock conditions (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypoglycaemic and neurogenic shock conditions (narrow), Gastrointestinal haemorrhage (narrow), Oropharyngeal infections (narrow), Acute central respiratory depression (narrow), Ischaemic colitis (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (narrow), Noninfectious diarrhoea (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1999-02-24
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: lotrisone cream
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: autopsy showed 8cm intussusception w/hyperemic necrosis & septic shock; also pos for RSV
CDC Split Type:

Write-up: 5 days p/vax pt treated in ER for gastroenteritis & pharyngitis. given phenergan & amoxicillin. 2/24/99 devel rectal bleeding; expired while awaiting transport to pediatric ICU


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