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

This is VAERS ID 179127

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Case Details

VAERS ID: 179127 (history)  
Form: Version 1.0  
Age: 0.25  
Sex: Male  
Location: Missouri  
Vaccinated:2001-11-27
Onset:2001-12-12
   Days after vaccination:15
Submitted: 2001-12-13
   Days after onset:1
Entered: 2001-12-18
   Days after submission:5
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS 514A2 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1067L / 2 RL / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES UA604AA / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / SANOFI PASTEUR T13902 / 1 LL / SC
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 480900 / 1 RL / IM

Administered by: Public       Purchased by: Public
Symptoms: Atelectasis, Coma, Eye discharge, Liver disorder, Nasal congestion, Nephritis, Petechiae, Pulmonary congestion, Pulmonary oedema
SMQs:, Acute renal failure (broad), Cardiac failure (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2001-12-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Completed antibiotic therapy 1 week ago for upper respiratory infection.
Current Illness: NONE
Preexisting Conditions: Respiratory infection 2-3 weeks ago.
Allergies:
Diagnostic Lab Data: Autopsy results pending
CDC Split Type:

Write-up: The parent reports the pt did not have any problems after his shots. He had an upper respiratory infection about 2-3 weeks ago and completed antibiotics about 1 week ago. He was seen in ER. The ER dx''d URI with nasal congestion. He had green matter in both eyes and that was dx''d as conjunctivitis and treated with Polysporin optical ointment. The child was fed a bottle of Enfamil with Iron about 10:00 and was found unresponsive and pronounced DOA at 11:41 at the hospital. The hospital will fax Health Dept report. The baby was found by coroner with a bottle propped in the crib with a pillow and stuffed animals. COD as per autopsy report -- undetermined. Per F/U 4/13/02: Pleural surfaces have focal petechiae and are atelectatic. Lungs show edema and congestion, the liver shows congestion and the kidneys show a focal area of chronic inflammation.


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