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

This is VAERS ID 179128

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Case Details

VAERS ID: 179128 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: Missouri  
Vaccinated:2001-11-28
Onset:2001-12-12
   Days after vaccination:14
Submitted: 2001-12-14
   Days after onset:2
Entered: 2001-12-18
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS 516A2 / 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 RL / SC
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 480900 / 1 RL / IM

Administered by: Public       Purchased by: Public
Symptoms: Anorexia, Coma, Musculoskeletal stiffness, Rhinitis allergic, Somnolence
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Dystonia (broad), Parkinson-like events (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypersensitivity (narrow), Arthritis (broad), Hypoglycaemia (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: Tylenol 24 hours after immunzation
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Autopsy results pending
CDC Split Type:

Write-up: Pt was fed Enfamil with Iron. At 20:15 the pt was asleep in his crib on his abdomen. He was found unresponsive at about 21:15. DOA at the hospital at about 21:20. Other family members were ill with vomiting for 2-3 days prior to his death. On 12/13/01 at 04:15, a call was received from the child''s mother, reporting that her son died last night and wanted to let the health dept know that Family Services will be calling us regarding immunizations given, dates and possible side effects. She expressed concern about Prevnar vaccine and infant''s death. She reported that "he just did not act like the same child after he got his shots." I asked her if he ran any fever after he received his shots and she said no. She was giving him Tylenol every 4 hours for 24 hours, post vax. She noticed his "appetite had decreased a little every day since he was immunized and that his muscles seemed tense. He was not really sick and sometimes he would laugh and smile but yesterday, he did not want to eat at all and just wanted to sleep all day." He was seen at ER with a "runny nose" (allergic rhinitis), no medications on 11/1/01. On 12/5/01, his 4 year old sister was vomiting 1/2 hour after eating. Grandmother sick with acute viral gastritis. Cause of Death as per autospy report - undetermined.


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