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This is VAERS ID 206895

Case Details

VAERS ID: 206895 (history)  
Form: Version 1.0  
Age: 1.29  
Sex: Female  
Location: California  
Vaccinated:2003-03-17
Onset:2003-05-22
   Days after vaccination:66
Submitted: 2003-07-23
   Days after onset:62
Entered: 2003-08-01
   Days after submission:9
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR - / UNK - / -
MMR: MEASLES + MUMPS + RUBELLA (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK - / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH - / UNK - / -
UNK: VACCINE NOT SPECIFIED (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK - / -

Administered by: Unknown       Purchased by: Unknown
Symptoms: Acidosis, Hepatic necrosis, Hepatitis, Renal failure, Respiratory failure, Sepsis, Thrombocytopenia
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Hepatitis, non-infectious (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Anaphylactic reaction (broad), Agranulocytosis (broad), Haematopoietic thrombocytopenia (narrow), Lactic acidosis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Systemic lupus erythematosus (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Chronic kidney disease (narrow), Hypersensitivity (broad), Tumour lysis syndrome (narrow), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypokalaemia (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2003-05-31
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 7 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: 200301423

Write-up: This subject is a one year old female, who was admitted to the hospital due to systemic inflammatory response syndrome while enrolled in a Phase IV Daptacel study. The subject received one dose of Daptacel vaccine: along with other pediatric vaccines on 3/17/03. The subject developed symptoms 65 days post immunization and was admitted to the hospital three days later 5/25/03. The subject was transferred from hospital to another hospital on 5/26/03 with the diagnosis of acute respiratory failure, presumed streptococcal sepsis and hepatitis. While at hospital, the pt expired on 5/31/03 with a diagnosis of SIRS, acidosis and acute liver necrosis. The event of systemic inflammatory response syndrome was reported by the investigator as unrelated to the study vaccine. No autopsy was performed. Follow up on 04/21/04: "New version created to place Infanrix into pt''s history screen." Medical Records received on 8/05/2003 states kidney failure and thrombocytopenia.


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