| VAERS ID: |
189882 (history) |
| Form: |
Version 1.0 |
| Age: |
|
| Sex: |
Male |
| Location: |
New York |
| Vaccinated: | 1997-06-12 |
| Onset: | 1997-06-12 |
| Days after vaccination: | 0 |
| Submitted: |
2002-09-03 |
| Days after onset: | 1909 |
| Entered: |
2002-09-10 |
| Days after submission: | 7 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH |
444259 / 4 |
LL / - |
| HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM |
2371A2 / 4 |
- / - |
| MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. |
0009E / 2 |
- / - |
| OPV: POLIO VIRUS, ORAL (NO BRAND NAME) / PFIZER/WYETH |
0760 / 3 |
LL / - |
Administered by: Private Purchased by: Other
Symptoms: Chromosome abnormality,
Drug administration error,
Lethargy
SMQs:, Congenital, familial and genetic disorders (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Medication errors (narrow), Hypoglycaemia (broad)
Life Threatening? Yes
Birth Defect? No
Died? Yes
Date died: 2000-09-25
Days after onset: 1201
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: Born with a 5mm ventrical septal defect-healed by age 20 mos.
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: Pt was given an "extra hep B" shot in error. He became lethargic for three days after the vaccines were administered. Pt died from Adrenoleukodystrophy. His mother was not the carrier, symptoms of ALD began three months after vaccines. |
