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

This is VAERS ID 127161

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Case Details

VAERS ID: 127161 (history)  
Form: Version 1.0  
Age: 0.3  
Sex: Male  
Location: California  
Vaccinated:1999-07-12
Onset:1999-07-14
   Days after vaccination:2
Submitted: 1999-08-05
   Days after onset:22
Entered: 1999-08-13
   Days after submission:8
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 2958AZ / 1 LL / -
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. P01263 / 1 LL / -
RV: ROTAVIRUS (ROTASHIELD) / PFIZER/WYETH 4988133 / 1 MO / PO

Administered by: Private       Purchased by: Unknown
Symptoms: Agitation, Apnoea, Cardiac arrest, Coma, Encephalopathy, Gastrointestinal disorder, Gastrointestinal malformation, Ileus, Intestinal obstruction, Large intestine perforation, Lung disorder, Mesenteric occlusion, Pallor, Pneumonia, Respiratory disorder, Sepsis, Shock
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), 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), Dementia (broad), Congenital, familial and genetic disorders (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Gastrointestinal obstruction (narrow), Gastrointestinal perforation (narrow), Acute central respiratory depression (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Noninfectious meningitis (broad), Hostility/aggression (broad), Ischaemic colitis (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Hypersensitivity (narrow), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Sepsis (narrow), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 1999-07-15
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations: none known~ ()~~~In patient
Other Medications: dtap & hib 6/1/99
Current Illness: none
Preexisting Conditions: s/p duodenal atresia repair; s/p lysis of adhesions
Allergies:
Diagnostic Lab Data: disrupted cecum, abd fall of bowel contents; mesentery thrombosed; much of bowel ischemic;post mortem exam, final results pending;
CDC Split Type:

Write-up: 2day p/vax 5:30pm unusual cry; pallor, taken to ER; mom suspected bowel obstruction; xray showed ileus; 7:30pm cardiac arrest: resuscitation/unconscious; sent to UCSF; 7/15 remained unstable,no possibility of surgery as result;pt died 7/15;


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