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This is VAERS ID 207834

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 207834
VAERS Form:
Age:18.0
Sex:Male
Location:California
Vaccinated:2002-11-14
Onset:0000-00-00
Submitted:2003-08-11
Entered:2003-08-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (FLUZONE) / AVENTIS PASTEUR, - / - - / -
HEP: HEP B (UNKNOWN MFR) / UNKNOWN MFR - / - - / -
HEPA: HEP A (UNKNOWN MFR) / UNKNOWN MFR - / - - / -
MEN: MENINGOCOCCAL (MENOMUNE) / AVENTIS PASTEUR, UB245AA / - - / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. - / - - / -
PPV: PNEUMO, 23-VALENT (PNEUMOVAX) / MERCK & CO. INC. - / - - / -

Administered by: Military      Purchased by: Unknown
Symptoms: DYSPNEA, NO DRUG EFFECT, COUGH INC, LAB TEST ABNORM, INFECT BACT

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2002-12-15
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up:


Changed on 12/8/2009

VAERS ID: 207834 Before After
VAERS Form:
Age:18.0
Sex:Male
Location:California
Vaccinated:2002-11-14
Onset:0000-00-00
Submitted:2003-08-11
Entered:2003-08-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (FLUZONE) INFLUENZA (SEASONAL) (FLUZONE) / AVENTIS PASTEUR, AVENTIS PASTEUR - / - - / -
HEP: HEP B (UNKNOWN MFR) HEP B (NO BRAND NAME) / UNKNOWN MFR UNKNOWN MANUFACTURER - / - - / -
HEPA: HEP A (UNKNOWN MFR) HEP A (NO BRAND NAME) / UNKNOWN MFR UNKNOWN MANUFACTURER - / - - / -
MEN: MENINGOCOCCAL (MENOMUNE) / AVENTIS PASTEUR, AVENTIS PASTEUR UB245AA / - - / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. - / - - / -
PPV: PNEUMO, 23-VALENT (PNEUMOVAX) PNEUMO (PNEUMOVAX) / MERCK & CO. INC. - / - - / -

Administered by: Military      Purchased by: Unknown
Symptoms: Cough, Drug ineffective, Dyspnoea, Laboratory test abnormal, Pharyngitis, Rash maculo-papular, Sepsis, Shock, Bacterial infection, DYSPNEA, NO DRUG EFFECT, COUGH INC, LAB TEST ABNORM, INFECT BACT

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2002-12-15
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: PPD
Current Illness:
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Diagnostic Laboratory: PCR was positive for Neisseria Meningococcal infection serogroup C.
CDC 'Split Type': (blank) 200301574

Write-up: From initial information received on 8/7/03 from a medical professional, regarding an adverse event occurring in the US, it was reported that an 18year old male patient received MENOMUNE, lot number UB245AA, FLUZONE (lot number not reported), TUBERSOL (lot number not reported), HEPATITIS A VACCINE (lot number and manufacturer not reported, HEPATITIS B VACCINE (lot number and manufacturer not reported), MMR (lot number not reported), and PNEUMOVAX (lot number not reported) administered on 11/14/02. All vaccines were administered on the same date. The patient died on 12/15/02. The CDC investigation confirmed that the patient was positive for serogroup C, Meningococcal infection. The onset date of signs and symptoms were not reported. An autopsy was performed, however, results were not available at the time of this report. Follow-up information: Information has been received from a health professional concerning an 18 year old male patient who was healthy with no adverse entry who on 11/14/2002 was vaccinated with a dose of MMRII (Lot # not reported). Concomitant therapy on 11/14/2002 included a dose of hepatitis A vaccine (inactive) (manufacturer unknown) (Lot # not reported), a dose of hepatitis B virus vaccine rHBsAg (yeast) (manufacturer unknown) (Lot # not reported), a dose of pneumococcal vaccine 23 polyvalent (MSD) (Lot # not reported), a dose of tuberculin in purified protein derivative (TUBERSOL) (Lot # not reported), a dose of influenza virus vaccine (FLUZONE) (Lot # not reported) and a dose of meningococcal polysaccharide vaccine (MENOMUME-A/C/Y/W-135) (Lot # UB245AA). Subsequently the patient died on 12/15/2002. It was confirmed that the patient was positive for serogroup C Meningococcal infection. The onset date of signs and symptoms were not reported. An autopsy was performed; however, the results were not available at the time of the report. From additional information received on 08/12/2003 from a pathology department, it was reported that the patient presented with an acute onset of a rash on


Changed on 1/5/2010

VAERS ID: 207834 Before After
VAERS Form:
Age:18.0
Sex:Male
Location:California
Vaccinated:2002-11-14
Onset:0000-00-00
Submitted:2003-08-11
Entered:2003-08-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUZONE) / AVENTIS PASTEUR SANOFI PASTEUR - / - - / -
HEP: HEP B (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - - / -
HEPA: HEP A (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - - / -
MEN: MENINGOCOCCAL (MENOMUNE) / AVENTIS PASTEUR SANOFI PASTEUR UB245AA / - - / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. - / - - / -
PPV: PNEUMO (PNEUMOVAX) / MERCK & CO. INC. - / - - / -

Administered by: Military      Purchased by: Unknown
Symptoms: Cough, Drug ineffective, Dyspnoea, Laboratory test abnormal, Pharyngitis, Rash maculo-papular, Respiratory distress, Sepsis, Shock, Bacterial infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2002-12-15
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: PPD
Current Illness:
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Diagnostic Laboratory: PCR was positive for Neisseria Meningococcal infection serogroup C.
CDC 'Split Type': 200301574

Write-up: From initial information received on 8/7/03 from a medical professional, regarding an adverse event occurring in the US, it was reported that an 18year old male patient received MENOMUNE, lot number UB245AA, FLUZONE (lot number not reported), TUBERSOL (lot number not reported), HEPATITIS A VACCINE (lot number and manufacturer not reported, HEPATITIS B VACCINE (lot number and manufacturer not reported), MMR (lot number not reported), and PNEUMOVAX (lot number not reported) administered on 11/14/02. All vaccines were administered on the same date. The patient died on 12/15/02. The CDC investigation confirmed that the patient was positive for serogroup C, Meningococcal infection. The onset date of signs and symptoms were not reported. An autopsy was performed, however, results were not available at the time of this report. Follow-up information: Information has been received from a health professional concerning an 18 year old male patient who was healthy with no adverse entry who on 11/14/2002 was vaccinated with a dose of MMRII (Lot # not reported). Concomitant therapy on 11/14/2002 included a dose of hepatitis A vaccine (inactive) (manufacturer unknown) (Lot # not reported), a dose of hepatitis B virus vaccine rHBsAg (yeast) (manufacturer unknown) (Lot # not reported), a dose of pneumococcal vaccine 23 polyvalent (MSD) (Lot # not reported), a dose of tuberculin in purified protein derivative (TUBERSOL) (Lot # not reported), a dose of influenza virus vaccine (FLUZONE) (Lot # not reported) and a dose of meningococcal polysaccharide vaccine (MENOMUME-A/C/Y/W-135) (Lot # UB245AA). Subsequently the patient died on 12/15/2002. It was confirmed that the patient was positive for serogroup C Meningococcal infection. The onset date of signs and symptoms were not reported. An autopsy was performed; however, the results were not available at the time of the report. From additional information received on 08/12/2003 from a pathology department, it was reported that the patient presented with an acute onset of a rash on


Changed on 1/4/2011

VAERS ID: 207834 Before After
VAERS Form:
Age:18.0
Sex:Male
Location:California
Vaccinated:2002-11-14
Onset:0000-00-00
Submitted:2003-08-11
Entered:2003-08-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR - / - - / -
HEP: HEP B (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - - / -
HEPA: HEP A (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - - / -
MEN: MENINGOCOCCAL (MENOMUNE) / SANOFI PASTEUR UB245AA / - - / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. - / - - / -
PPV: PNEUMO (PNEUMOVAX) / MERCK & CO. INC. - / - - / -

Administered by: Military      Purchased by: Unknown
Symptoms: Cough, Drug ineffective, Dyspnoea, Laboratory test abnormal, Pharyngitis, Rash maculo-papular, Respiratory distress, Sepsis, Shock, Bacterial infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2002-12-15
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: PPD
Current Illness:
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Diagnostic Laboratory: PCR was positive for Neisseria Meningococcal infection serogroup C.
CDC 'Split Type': 200301574

Write-up: From initial information received on 8/7/03 from a medical professional, regarding an adverse event occurring in the US, it was reported that an 18year old male patient received MENOMUNE, lot number UB245AA, FLUZONE (lot number not reported), TUBERSOL (lot number not reported), HEPATITIS A VACCINE (lot number and manufacturer not reported, HEPATITIS B VACCINE (lot number and manufacturer not reported), MMR (lot number not reported), and PNEUMOVAX (lot number not reported) administered on 11/14/02. All vaccines were administered on the same date. The patient died on 12/15/02. The CDC investigation confirmed that the patient was positive for serogroup C, Meningococcal infection. The onset date of signs and symptoms were not reported. An autopsy was performed, however, results were not available at the time of this report. Follow-up information: Information has been received from a health professional concerning an 18 year old male patient who was healthy with no adverse entry who on 11/14/2002 was vaccinated with a dose of MMRII (Lot # not reported). Concomitant therapy on 11/14/2002 included a dose of hepatitis A vaccine (inactive) (manufacturer unknown) (Lot # not reported), a dose of hepatitis B virus vaccine rHBsAg (yeast) (manufacturer unknown) (Lot # not reported), a dose of pneumococcal vaccine 23 polyvalent (MSD) (Lot # not reported), a dose of tuberculin in purified protein derivative (TUBERSOL) (Lot # not reported), a dose of influenza virus vaccine (FLUZONE) (Lot # not reported) and a dose of meningococcal polysaccharide vaccine (MENOMUME-A/C/Y/W-135) (Lot # UB245AA). Subsequently the patient died on 12/15/2002. It was confirmed that the patient was positive for serogroup C Meningococcal infection. The onset date of signs and symptoms were not reported. An autopsy was performed; however, the results were not available at the time of the report. From additional information received on 08/12/2003 from a pathology department, it was reported that the patient presented with an acute onset of a rash on his feet that spread to his face over a period of a few hours, after a 3 day history of a cough and sore throat. The symptoms progressed rapidly to severe respiratory distress and shock. The patient was treated with advanced cardiac life support in the ICU (intensive care unit) and died within three hours of presenting to the hospital. The patient died at 1:01 pm on 12/15/2002; the autopsy was done the following day and showed that the cause of death was Neisseria Meningitidis Septicemia (Meningococcemia). Gross autopsy findings included evidence acute shock syndrome with diffuse petechia and hemorrhage to multiple organs, visceral congestions, shock kidneys, and a blothcy erythematous rash to the organs and a few scattered foci of acute inflammation within the myocardium and meninges. The clinical presentation, autopsy findings, and laboratory PCR results were consistent with Neisseria Meningitidis (meningococcal) Septicemia (special pathogens branch # M10158). The manner of death was natural. The CDC confirmed that the patient was positive for serogroup C Meningococcal infection. Final anatomical diagnosis from the autopsy report included: Diffuse discrete petechiae and small hemorrhages involving multiple organs, serosa and mucosal surfaces (intestines, mesentery, epicardium, myocardium, renal cortex, adrenals, lungs, pharynx, bronchi, skeletal muscle and conjuctica), pulmonary edema and visceral congestion, bilateral pleural and pericardial effusions, blotchy erythematous rash on face, trunk, arms and legs, shock kidneys with diffuse pale cortices. there was no purulent meningeal exudates present. The PCR results were positive for Neisseria Meningitidis Serogroup C. Microscopic findings included: Numerous fibrin micro thrombi in heart, lungs, liver, glomeruli, brain and oropharynx and scattered small foci of acute inflammation in meninges and myocardium associated with hemorrhage and focal myocyte necro


Changed on 7/7/2013

VAERS ID: 207834 Before After
VAERS Form:
Age:18.0
Sex:Male
Location:California
Vaccinated:2002-11-14
Onset:0000-00-00
Submitted:2003-08-11
Entered:2003-08-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR - / - - / -
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR - / - - / -
HEP: HEP B (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - - / -
HEPA: HEP A (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - - / -
MEN: MENINGOCOCCAL (MENOMUNE) / SANOFI PASTEUR UB245AA / - - / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. - / - - / -
PPV: PNEUMO (PNEUMOVAX) / MERCK & CO. INC. - / - - / -

Administered by: Military      Purchased by: Unknown
Symptoms: Cough, Drug ineffective, Dyspnoea, Laboratory test abnormal, Pharyngitis, Rash maculo-papular, Respiratory distress, Sepsis, Shock, Bacterial infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2002-12-15
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: PPD
Current Illness:
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Diagnostic Laboratory: PCR was positive for Neisseria Meningococcal infection serogroup C.
CDC 'Split Type': 200301574

Write-up: From initial information received on 8/7/03 from a medical professional, regarding an adverse event occurring in the US, it was reported that an 18year old male patient received MENOMUNE, lot number UB245AA, FLUZONE (lot number not reported), TUBERSOL (lot number not reported), HEPATITIS A VACCINE (lot number and manufacturer not reported, HEPATITIS B VACCINE (lot number and manufacturer not reported), MMR (lot number not reported), and PNEUMOVAX (lot number not reported) administered on 11/14/02. All vaccines were administered on the same date. The patient died on 12/15/02. The CDC investigation confirmed that the patient was positive for serogroup C, Meningococcal infection. The onset date of signs and symptoms were not reported. An autopsy was performed, however, results were not available at the time of this report. Follow-up information: Information has been received from a health professional concerning an 18 year old male patient who was healthy with no adverse entry who on 11/14/2002 was vaccinated with a dose of MMRII (Lot # not reported). Concomitant therapy on 11/14/2002 included a dose of hepatitis A vaccine (inactive) (manufacturer unknown) (Lot # not reported), a dose of hepatitis B virus vaccine rHBsAg (yeast) (manufacturer unknown) (Lot # not reported), a dose of pneumococcal vaccine 23 polyvalent (MSD) (Lot # not reported), a dose of tuberculin in purified protein derivative (TUBERSOL) (Lot # not reported), a dose of influenza virus vaccine (FLUZONE) (Lot # not reported) and a dose of meningococcal polysaccharide vaccine (MENOMUME-A/C/Y/W-135) (Lot # UB245AA). Subsequently the patient died on 12/15/2002. It was confirmed that the patient was positive for serogroup C Meningococcal infection. The onset date of signs and symptoms were not reported. An autopsy was performed; however, the results were not available at the time of the report. From additional information received on 08/12/2003 from a pathology department, it was reported that the patient presented with an acute onset of a rash on his feet that spread to his face over a period of a few hours, after a 3 day history of a cough and sore throat. The symptoms progressed rapidly to severe respiratory distress and shock. The patient was treated with advanced cardiac life support in the ICU (intensive care unit) and died within three hours of presenting to the hospital. The patient died at 1:01 pm on 12/15/2002; the autopsy was done the following day and showed that the cause of death was Neisseria Meningitidis Septicemia (Meningococcemia). Gross autopsy findings included evidence acute shock syndrome with diffuse petechia and hemorrhage to multiple organs, visceral congestions, shock kidneys, and a blothcy erythematous rash to the organs and a few scattered foci of acute inflammation within the myocardium and meninges. The clinical presentation, autopsy findings, and laboratory PCR results were consistent with Neisseria Meningitidis (meningococcal) Septicemia (special pathogens branch # M10158). The manner of death was natural. The CDC confirmed that the patient was positive for serogroup C Meningococcal infection. Final anatomical diagnosis from the autopsy report included: Diffuse discrete petechiae and small hemorrhages involving multiple organs, serosa and mucosal surfaces (intestines, mesentery, epicardium, myocardium, renal cortex, adrenals, lungs, pharynx, bronchi, skeletal muscle and conjuctica), pulmonary edema and visceral congestion, bilateral pleural and pericardial effusions, blotchy erythematous rash on face, trunk, arms and legs, shock kidneys with diffuse pale cortices. there was no purulent meningeal exudates present. The PCR results were positive for Neisseria Meningitidis Serogroup C. Microscopic findings included: Numerous fibrin micro thrombi in heart, lungs, liver, glomeruli, brain and oropharynx and scattered small foci of acute inflammation in meninges and myocardium associated with hemorrhage and focal myocyte necro


Changed on 6/14/2014

VAERS ID: 207834 Before After
VAERS Form:
Age:18.0
Sex:Male
Location:California
Vaccinated:2002-11-14
Onset:0000-00-00
Submitted:2003-08-11
Entered:2003-08-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR - / - - / -
HEP: HEP B (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - - / -
HEPA: HEP A (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - - / -
MEN: MENINGOCOCCAL (MENOMUNE) / SANOFI PASTEUR UB245AA / - - / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. - / - - / -
PPV: PNEUMO (PNEUMOVAX) / MERCK & CO. INC. - / - - / -

Administered by: Military      Purchased by: Unknown
Symptoms: Cough, Drug ineffective, Dyspnoea, Laboratory test abnormal, Pharyngitis, Rash maculo-papular, Respiratory distress, Sepsis, Shock, Bacterial infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2002-12-15
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: PPD
Current Illness:
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Diagnostic Laboratory: PCR was positive for Neisseria Meningococcal infection serogroup C.
CDC 'Split Type': 200301574

Write-up: From initial information received on 8/7/03 from a medical professional, regarding an adverse event occurring in the US, it was reported that an 18year old male patient received MENOMUNE, lot number UB245AA, FLUZONE (lot number not reported), TUBERSOL (lot number not reported), HEPATITIS A VACCINE (lot number and manufacturer not reported, HEPATITIS B VACCINE (lot number and manufacturer not reported), MMR (lot number not reported), and PNEUMOVAX (lot number not reported) administered on 11/14/02. All vaccines were administered on the same date. The patient died on 12/15/02. The CDC investigation confirmed that the patient was positive for serogroup C, Meningococcal infection. The onset date of signs and symptoms were not reported. An autopsy was performed, however, results were not available at the time of this report. Follow-up information: Information has been received from a health professional concerning an 18 year old male patient who was healthy with no adverse entry who on 11/14/2002 was vaccinated with a dose of MMRII (Lot # not reported). Concomitant therapy on 11/14/2002 included a dose of hepatitis A vaccine (inactive) (manufacturer unknown) (Lot # not reported), a dose of hepatitis B virus vaccine rHBsAg (yeast) (manufacturer unknown) (Lot # not reported), a dose of pneumococcal vaccine 23 polyvalent (MSD) (Lot # not reported), a dose of tuberculin in purified protein derivative (TUBERSOL) (Lot # not reported), a dose of influenza virus vaccine (FLUZONE) (Lot # not reported) and a dose of meningococcal polysaccharide vaccine (MENOMUME-A/C/Y/W-135) (Lot # UB245AA). Subsequently the patient died on 12/15/2002. It was confirmed that the patient was positive for serogroup C Meningococcal infection. The onset date of signs and symptoms were not reported. An autopsy was performed; however, the results were not available at the time of the report. From additional information received on 08/12/2003 from a pathology department, it was reported that the patient presented with an acute onset of a rash on his feet that spread to his face over a period of a few hours, after a 3 day history of a cough and sore throat. The symptoms progressed rapidly to severe respiratory distress and shock. The patient was treated with advanced cardiac life support in the ICU (intensive care unit) and died within three hours of presenting to the hospital. The patient died at 1:01 pm on 12/15/2002; the autopsy was done the following day and showed that the cause of death was Neisseria Meningitidis Septicemia (Meningococcemia). Gross autopsy findings included evidence acute shock syndrome with diffuse petechia and hemorrhage to multiple organs, visceral congestions, shock kidneys, and a blothcy erythematous rash to the organs and a few scattered foci of acute inflammation within the myocardium and meninges. The clinical presentation, autopsy findings, and laboratory PCR results were consistent with Neisseria Meningitidis (meningococcal) Septicemia (special pathogens branch # M10158). The manner of death was natural. The CDC confirmed that the patient was positive for serogroup C Meningococcal infection. Final anatomical diagnosis from the autopsy report included: Diffuse discrete petechiae and small hemorrhages involving multiple organs, serosa and mucosal surfaces (intestines, mesentery, epicardium, myocardium, renal cortex, adrenals, lungs, pharynx, bronchi, skeletal muscle and conjuctica), pulmonary edema and visceral congestion, bilateral pleural and pericardial effusions, blotchy erythematous rash on face, trunk, arms and legs, shock kidneys with diffuse pale cortices. there was no purulent meningeal exudates present. The PCR results were positive for Neisseria Meningitidis Serogroup C. Microscopic findings included: Numerous fibrin micro thrombi in heart, lungs, liver, glomeruli, brain and oropharynx and scattered small foci of acute inflammation in meninges and myocardium associated with hemorrhage and focal myocyte necro


Changed on 2/14/2017

VAERS ID: 207834 Before After
VAERS Form:
Age:18.0
Sex:Male
Location:California
Vaccinated:2002-11-14
Onset:0000-00-00
Submitted:2003-08-11
Entered:2003-08-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR - / - - / -
HEP: HEP B (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - - / -
HEPA: HEP A (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - - / -
MEN: MENINGOCOCCAL (MENOMUNE) / SANOFI PASTEUR UB245AA / - - / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. - / - - / -
PPV: PNEUMO (PNEUMOVAX) / MERCK & CO. INC. - / - - / -

Administered by: Military      Purchased by: Unknown
Symptoms: Cough, Drug ineffective, Dyspnoea, Laboratory test abnormal, Pharyngitis, Rash maculo-papular, Respiratory distress, Sepsis, Shock, Bacterial infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2002-12-15
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: PPD
Current Illness:
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Diagnostic Laboratory: PCR was positive for Neisseria Meningococcal infection serogroup C.
CDC 'Split Type': 200301574

Write-up: From initial information received on 8/7/03 from a medical professional, regarding an adverse event occurring in the US, it was reported that an 18year old male patient received MENOMUNE, lot number UB245AA, FLUZONE (lot number not reported), TUBERSOL (lot number not reported), HEPATITIS A VACCINE (lot number and manufacturer not reported, HEPATITIS B VACCINE (lot number and manufacturer not reported), MMR (lot number not reported), and PNEUMOVAX (lot number not reported) administered on 11/14/02. All vaccines were administered on the same date. The patient died on 12/15/02. The CDC investigation confirmed that the patient was positive for serogroup C, Meningococcal infection. The onset date of signs and symptoms were not reported. An autopsy was performed, however, results were not available at the time of this report. Follow-up information: Information has been received from a health professional concerning an 18 year old male patient who was healthy with no adverse entry who on 11/14/2002 was vaccinated with a dose of MMRII (Lot # not reported). Concomitant therapy on 11/14/2002 included a dose of hepatitis A vaccine (inactive) (manufacturer unknown) (Lot # not reported), a dose of hepatitis B virus vaccine rHBsAg (yeast) (manufacturer unknown) (Lot # not reported), a dose of pneumococcal vaccine 23 polyvalent (MSD) (Lot # not reported), a dose of tuberculin in purified protein derivative (TUBERSOL) (Lot # not reported), a dose of influenza virus vaccine (FLUZONE) (Lot # not reported) and a dose of meningococcal polysaccharide vaccine (MENOMUME-A/C/Y/W-135) (Lot # UB245AA). Subsequently the patient died on 12/15/2002. It was confirmed that the patient was positive for serogroup C Meningococcal infection. The onset date of signs and symptoms were not reported. An autopsy was performed; however, the results were not available at the time of the report. From additional information received on 08/12/2003 from a pathology department, it was reported that the patient presented with an acute onset of a rash on his feet that spread to his face over a period of a few hours, after a 3 day history of a cough and sore throat. The symptoms progressed rapidly to severe respiratory distress and shock. The patient was treated with advanced cardiac life support in the ICU (intensive care unit) and died within three hours of presenting to the hospital. The patient died at 1:01 pm on 12/15/2002; the autopsy was done the following day and showed that the cause of death was Neisseria Meningitidis Septicemia (Meningococcemia). Gross autopsy findings included evidence acute shock syndrome with diffuse petechia and hemorrhage to multiple organs, visceral congestions, shock kidneys, and a blothcy erythematous rash to the organs and a few scattered foci of acute inflammation within the myocardium and meninges. The clinical presentation, autopsy findings, and laboratory PCR results were consistent with Neisseria Meningitidis (meningococcal) Septicemia (special pathogens branch # M10158). The manner of death was natural. The CDC confirmed that the patient was positive for serogroup C Meningococcal infection. Final anatomical diagnosis from the autopsy report included: Diffuse discrete petechiae and small hemorrhages involving multiple organs, serosa and mucosal surfaces (intestines, mesentery, epicardium, myocardium, renal cortex, adrenals, lungs, pharynx, bronchi, skeletal muscle and conjuctica), pulmonary edema and visceral congestion, bilateral pleural and pericardial effusions, blotchy erythematous rash on face, trunk, arms and legs, shock kidneys with diffuse pale cortices. there was no purulent meningeal exudates present. The PCR results were positive for Neisseria Meningitidis Serogroup C. Microscopic findings included: Numerous fibrin micro thrombi in heart, lungs, liver, glomeruli, brain and oropharynx and scattered small foci of acute inflammation in meninges and myocardium associated with hemorrhage and focal myocyte necro


Changed on 9/14/2017

VAERS ID: 207834 Before After
VAERS Form:(blank) 1
Age:18.0
Sex:Male
Location:California
Vaccinated:2002-11-14
Onset:0000-00-00
Submitted:2003-08-11
Entered:2003-08-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR - / - UNK - / -
HEP: HEP B (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - UNK - / -
HEPA: HEP A (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - UNK - / -
MEN: MENINGOCOCCAL (MENOMUNE) / SANOFI PASTEUR UB245AA / - UNK - / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. - / - UNK - / -
PPV: PNEUMO (PNEUMOVAX) / MERCK & CO. INC. - / - UNK - / -

Administered by: Military      Purchased by: Unknown
Symptoms: Cough, Drug ineffective, Dyspnoea, Laboratory test abnormal, Pharyngitis, Rash maculo-papular, Respiratory distress, Sepsis, Shock, Bacterial infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2002-12-15
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: PPD
Current Illness:
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Diagnostic Laboratory: PCR was positive for Neisseria Meningococcal infection serogroup C.
CDC 'Split Type': 200301574

Write-up: From initial information received on 8/7/03 from a medical professional, regarding an adverse event occurring in the US, it was reported that an 18year old male patient received MENOMUNE, lot number UB245AA, FLUZONE (lot number not reported), TUBERSOL (lot number not reported), HEPATITIS A VACCINE (lot number and manufacturer not reported, HEPATITIS B VACCINE (lot number and manufacturer not reported), MMR (lot number not reported), and PNEUMOVAX (lot number not reported) administered on 11/14/02. All vaccines were administered on the same date. The patient died on 12/15/02. The CDC investigation confirmed that the patient was positive for serogroup C, Meningococcal infection. The onset date of signs and symptoms were not reported. An autopsy was performed, however, results were not available at the time of this report. Follow-up information: Information has been received from a health professional concerning an 18 year old male patient who was healthy with no adverse entry who on 11/14/2002 was vaccinated with a dose of MMRII (Lot # not reported). Concomitant therapy on 11/14/2002 included a dose of hepatitis A vaccine (inactive) (manufacturer unknown) (Lot # not reported), a dose of hepatitis B virus vaccine rHBsAg (yeast) (manufacturer unknown) (Lot # not reported), a dose of pneumococcal vaccine 23 polyvalent (MSD) (Lot # not reported), a dose of tuberculin in purified protein derivative (TUBERSOL) (Lot # not reported), a dose of influenza virus vaccine (FLUZONE) (Lot # not reported) and a dose of meningococcal polysaccharide vaccine (MENOMUME-A/C/Y/W-135) (Lot # UB245AA). Subsequently the patient died on 12/15/2002. It was confirmed that the patient was positive for serogroup C Meningococcal infection. The onset date of signs and symptoms were not reported. An autopsy was performed; however, the results were not available at the time of the report. From additional information received on 08/12/2003 from a pathology department, it was reported that the patient presented with an acute onset of a rash on his feet that spread to his face over a period of a few hours, after a 3 day history of a cough and sore throat. The symptoms progressed rapidly to severe respiratory distress and shock. The patient was treated with advanced cardiac life support in the ICU (intensive care unit) and died within three hours of presenting to the hospital. The patient died at 1:01 pm on 12/15/2002; the autopsy was done the following day and showed that the cause of death was Neisseria Meningitidis Septicemia (Meningococcemia). Gross autopsy findings included evidence acute shock syndrome with diffuse petechia and hemorrhage to multiple organs, visceral congestions, shock kidneys, and a blothcy erythematous rash to the organs and a few scattered foci of acute inflammation within the myocardium and meninges. The clinical presentation, autopsy findings, and laboratory PCR results were consistent with Neisseria Meningitidis (meningococcal) Septicemia (special pathogens branch # M10158). The manner of death was natural. The CDC confirmed that the patient was positive for serogroup C Meningococcal infection. Final anatomical diagnosis from the autopsy report included: Diffuse discrete petechiae and small hemorrhages involving multiple organs, serosa and mucosal surfaces (intestines, mesentery, epicardium, myocardium, renal cortex, adrenals, lungs, pharynx, bronchi, skeletal muscle and conjuctica), pulmonary edema and visceral congestion, bilateral pleural and pericardial effusions, blotchy erythematous rash on face, trunk, arms and legs, shock kidneys with diffuse pale cortices. there was no purulent meningeal exudates present. The PCR results were positive for Neisseria Meningitidis Serogroup C. Microscopic findings included: Numerous fibrin micro thrombi in heart, lungs, liver, glomeruli, brain and oropharynx and scattered small foci of acute inflammation in meninges and myocardium associated with hemorrhage and focal myocyte necro necrosis. Microscopic descriptions included: Trachea-diffuse mucosal and submucosal hemorrhage without inflammation. Lung-diffuse alveolar damage with numerous scattered fibrin and conspicous granulocytes present in red pulp. Liver-sinusoidal congestion with sinusoids distended by granulocytes and scattered fibrin micro thrombi. Prostate and bladder-mucosal and glandular autolysis, no pathologic diagnosis. There were no radiographs taken. Toxicology results included: Volatiles-the blood and vitereous fluid were examined for the presence of ethanol at a cutoff of 20 mg/dl. No ethanol was detected. The following drugs were detected: Positive Lidocaine-Lidocaine was detected in the liver by gas chromatography and confirmed by gas chromatography/mass spectrometry. Positive Atropine-Atropine was detected in the liver by gas chromatography/mass.


Changed on 2/14/2018

VAERS ID: 207834 Before After
VAERS Form:1
Age:18.0
Sex:Male
Location:California
Vaccinated:2002-11-14
Onset:0000-00-00
Submitted:2003-08-11
Entered:2003-08-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR - / UNK - / -
HEP: HEP B (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK - / -
HEPA: HEP A (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK - / -
MEN: MENINGOCOCCAL (MENOMUNE) / SANOFI PASTEUR UB245AA / UNK - / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. - / UNK - / -
PPV: PNEUMO (PNEUMOVAX) / MERCK & CO. INC. - / UNK - / -

Administered by: Military      Purchased by: Unknown
Symptoms: Cough, Drug ineffective, Dyspnoea, Laboratory test abnormal, Pharyngitis, Rash maculo-papular, Respiratory distress, Sepsis, Shock, Bacterial infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2002-12-15
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: PPD
Current Illness:
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Diagnostic Laboratory: PCR was positive for Neisseria Meningococcal infection serogroup C.
CDC 'Split Type': 200301574

Write-up: From initial information received on 8/7/03 from a medical professional, regarding an adverse event occurring in the US, it was reported that an 18year old male patient received MENOMUNE, lot number UB245AA, FLUZONE (lot number not reported), TUBERSOL (lot number not reported), HEPATITIS A VACCINE (lot number and manufacturer not reported, HEPATITIS B VACCINE (lot number and manufacturer not reported), MMR (lot number not reported), and PNEUMOVAX (lot number not reported) administered on 11/14/02. All vaccines were administered on the same date. The patient died on 12/15/02. The CDC investigation confirmed that the patient was positive for serogroup C, Meningococcal infection. The onset date of signs and symptoms were not reported. An autopsy was performed, however, results were not available at the time of this report. Follow-up information: Information has been received from a health professional concerning an 18 year old male patient who was healthy with no adverse entry who on 11/14/2002 was vaccinated with a dose of MMRII (Lot # not reported). Concomitant therapy on 11/14/2002 included a dose of hepatitis A vaccine (inactive) (manufacturer unknown) (Lot # not reported), a dose of hepatitis B virus vaccine rHBsAg (yeast) (manufacturer unknown) (Lot # not reported), a dose of pneumococcal vaccine 23 polyvalent (MSD) (Lot # not reported), a dose of tuberculin in purified protein derivative (TUBERSOL) (Lot # not reported), a dose of influenza virus vaccine (FLUZONE) (Lot # not reported) and a dose of meningococcal polysaccharide vaccine (MENOMUME-A/C/Y/W-135) (Lot # UB245AA). Subsequently the patient died on 12/15/2002. It was confirmed that the patient was positive for serogroup C Meningococcal infection. The onset date of signs and symptoms were not reported. An autopsy was performed; however, the results were not available at the time of the report. From additional information received on 08/12/2003 from a pathology department, it was reported that the patient presented with an acute onset of a rash on his feet that spread to his face over a period of a few hours, after a 3 day history of a cough and sore throat. The symptoms progressed rapidly to severe respiratory distress and shock. The patient was treated with advanced cardiac life support in the ICU (intensive care unit) and died within three hours of presenting to the hospital. The patient died at 1:01 pm on 12/15/2002; the autopsy was done the following day and showed that the cause of death was Neisseria Meningitidis Septicemia (Meningococcemia). Gross autopsy findings included evidence acute shock syndrome with diffuse petechia and hemorrhage to multiple organs, visceral congestions, shock kidneys, and a blothcy erythematous rash to the organs and a few scattered foci of acute inflammation within the myocardium and meninges. The clinical presentation, autopsy findings, and laboratory PCR results were consistent with Neisseria Meningitidis (meningococcal) Septicemia (special pathogens branch # M10158). The manner of death was natural. The CDC confirmed that the patient was positive for serogroup C Meningococcal infection. Final anatomical diagnosis from the autopsy report included: Diffuse discrete petechiae and small hemorrhages involving multiple organs, serosa and mucosal surfaces (intestines, mesentery, epicardium, myocardium, renal cortex, adrenals, lungs, pharynx, bronchi, skeletal muscle and conjuctica), pulmonary edema and visceral congestion, bilateral pleural and pericardial effusions, blotchy erythematous rash on face, trunk, arms and legs, shock kidneys with diffuse pale cortices. there was no purulent meningeal exudates present. The PCR results were positive for Neisseria Meningitidis Serogroup C. Microscopic findings included: Numerous fibrin micro thrombi in heart, lungs, liver, glomeruli, brain and oropharynx and scattered small foci of acute inflammation in meninges and myocardium associated with hemorrhage and focal myocyte necrosis. Microscopic descriptions included: Trachea-diffuse mucosal and submucosal hemorrhage without inflammation. Lung-diffuse alveolar damage with numerous scattered fibrin and conspicous granulocytes present in red pulp. Liver-sinusoidal congestion with sinusoids distended by granulocytes and scattered fibrin micro thrombi. Prostate and bladder-mucosal and glandular autolysis, no pathologic diagnosis. There were no radiographs taken. Toxicology results included: Volatiles-the blood and vitereous fluid were examined for the presence of ethanol at a cutoff of 20 mg/dl. No ethanol was detected. The following drugs were detected: Positive Lidocaine-Lidocaine was detected in the liver by gas chromatography and confirmed by gas chromatography/mass spectrometry. Positive Atropine-Atropine was detected in the liver by gas chromatography/mass.


Changed on 6/14/2018

VAERS ID: 207834 Before After
VAERS Form:1
Age:18.0
Sex:Male
Location:California
Vaccinated:2002-11-14
Onset:0000-00-00
Submitted:2003-08-11
Entered:2003-08-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR - / UNK - / -
HEP: HEP B (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK - / -
HEPA: HEP A (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK - / -
MEN: MENINGOCOCCAL (MENOMUNE) / SANOFI PASTEUR UB245AA / UNK - / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. - / UNK - / -
PPV: PNEUMO (PNEUMOVAX) / MERCK & CO. INC. - / UNK - / -

Administered by: Military      Purchased by: Unknown
Symptoms: Cough, Drug ineffective, Dyspnoea, Laboratory test abnormal, Pharyngitis, Rash maculo-papular, Respiratory distress, Sepsis, Shock, Bacterial infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2002-12-15
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: PPD
Current Illness:
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Diagnostic Laboratory: PCR was positive for Neisseria Meningococcal infection serogroup C.
CDC 'Split Type': 200301574

Write-up: From initial information received on 8/7/03 from a medical professional, regarding an adverse event occurring in the US, it was reported that an 18year old male patient received MENOMUNE, lot number UB245AA, FLUZONE (lot number not reported), TUBERSOL (lot number not reported), HEPATITIS A VACCINE (lot number and manufacturer not reported, HEPATITIS B VACCINE (lot number and manufacturer not reported), MMR (lot number not reported), and PNEUMOVAX (lot number not reported) administered on 11/14/02. All vaccines were administered on the same date. The patient died on 12/15/02. The CDC investigation confirmed that the patient was positive for serogroup C, Meningococcal infection. The onset date of signs and symptoms were not reported. An autopsy was performed, however, results were not available at the time of this report. Follow-up information: Information has been received from a health professional concerning an 18 year old male patient who was healthy with no adverse entry who on 11/14/2002 was vaccinated with a dose of MMRII (Lot # not reported). Concomitant therapy on 11/14/2002 included a dose of hepatitis A vaccine (inactive) (manufacturer unknown) (Lot # not reported), a dose of hepatitis B virus vaccine rHBsAg (yeast) (manufacturer unknown) (Lot # not reported), a dose of pneumococcal vaccine 23 polyvalent (MSD) (Lot # not reported), a dose of tuberculin in purified protein derivative (TUBERSOL) (Lot # not reported), a dose of influenza virus vaccine (FLUZONE) (Lot # not reported) and a dose of meningococcal polysaccharide vaccine (MENOMUME-A/C/Y/W-135) (Lot # UB245AA). Subsequently the patient died on 12/15/2002. It was confirmed that the patient was positive for serogroup C Meningococcal infection. The onset date of signs and symptoms were not reported. An autopsy was performed; however, the results were not available at the time of the report. From additional information received on 08/12/2003 from a pathology department, it was reported that the patient presented with an acute onset of a rash on his feet that spread to his face over a period of a few hours, after a 3 day history of a cough and sore throat. The symptoms progressed rapidly to severe respiratory distress and shock. The patient was treated with advanced cardiac life support in the ICU (intensive care unit) and died within three hours of presenting to the hospital. The patient died at 1:01 pm on 12/15/2002; the autopsy was done the following day and showed that the cause of death was Neisseria Meningitidis Septicemia (Meningococcemia). Gross autopsy findings included evidence acute shock syndrome with diffuse petechia and hemorrhage to multiple organs, visceral congestions, shock kidneys, and a blothcy erythematous rash to the organs and a few scattered foci of acute inflammation within the myocardium and meninges. The clinical presentation, autopsy findings, and laboratory PCR results were consistent with Neisseria Meningitidis (meningococcal) Septicemia (special pathogens branch # M10158). The manner of death was natural. The CDC confirmed that the patient was positive for serogroup C Meningococcal infection. Final anatomical diagnosis from the autopsy report included: Diffuse discrete petechiae and small hemorrhages involving multiple organs, serosa and mucosal surfaces (intestines, mesentery, epicardium, myocardium, renal cortex, adrenals, lungs, pharynx, bronchi, skeletal muscle and conjuctica), pulmonary edema and visceral congestion, bilateral pleural and pericardial effusions, blotchy erythematous rash on face, trunk, arms and legs, shock kidneys with diffuse pale cortices. there was no purulent meningeal exudates present. The PCR results were positive for Neisseria Meningitidis Serogroup C. Microscopic findings included: Numerous fibrin micro thrombi in heart, lungs, liver, glomeruli, brain and oropharynx and scattered small foci of acute inflammation in meninges and myocardium associated with hemorrhage and focal myocyte necrosis. Microscopic descriptions included: Trachea-diffuse mucosal and submucosal hemorrhage without inflammation. Lung-diffuse alveolar damage with numerous scattered fibrin and conspicous granulocytes present in red pulp. Liver-sinusoidal congestion with sinusoids distended by granulocytes and scattered fibrin micro thrombi. Prostate and bladder-mucosal and glandular autolysis, no pathologic diagnosis. There were no radiographs taken. Toxicology results included: Volatiles-the blood and vitereous fluid were examined for the presence of ethanol at a cutoff of 20 mg/dl. No ethanol was detected. The following drugs were detected: Positive Lidocaine-Lidocaine was detected in the liver by gas chromatography and confirmed by gas chromatography/mass spectrometry. Positive Atropine-Atropine was detected in the liver by gas chromatography/mass.


Changed on 8/14/2018

VAERS ID: 207834 Before After
VAERS Form:1
Age:18.0
Sex:Male
Location:California
Vaccinated:2002-11-14
Onset:0000-00-00
Submitted:2003-08-11
Entered:2003-08-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR - / UNK - / -
HEP: HEP B (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK - / -
HEPA: HEP A (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK - / -
MEN: MENINGOCOCCAL (MENOMUNE) / SANOFI PASTEUR UB245AA / UNK - / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. - / UNK - / -
PPV: PNEUMO (PNEUMOVAX) / MERCK & CO. INC. - / UNK - / -

Administered by: Military      Purchased by: Unknown
Symptoms: Cough, Drug ineffective, Dyspnoea, Laboratory test abnormal, Pharyngitis, Rash maculo-papular, Respiratory distress, Sepsis, Shock, Bacterial infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2002-12-15
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: PPD
Current Illness:
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Diagnostic Laboratory: PCR was positive for Neisseria Meningococcal infection serogroup C.
CDC 'Split Type': 200301574

Write-up: From initial information received on 8/7/03 from a medical professional, regarding an adverse event occurring in the US, it was reported that an 18year old male patient received MENOMUNE, lot number UB245AA, FLUZONE (lot number not reported), TUBERSOL (lot number not reported), HEPATITIS A VACCINE (lot number and manufacturer not reported, HEPATITIS B VACCINE (lot number and manufacturer not reported), MMR (lot number not reported), and PNEUMOVAX (lot number not reported) administered on 11/14/02. All vaccines were administered on the same date. The patient died on 12/15/02. The CDC investigation confirmed that the patient was positive for serogroup C, Meningococcal infection. The onset date of signs and symptoms were not reported. An autopsy was performed, however, results were not available at the time of this report. Follow-up information: Information has been received from a health professional concerning an 18 year old male patient who was healthy with no adverse entry who on 11/14/2002 was vaccinated with a dose of MMRII (Lot # not reported). Concomitant therapy on 11/14/2002 included a dose of hepatitis A vaccine (inactive) (manufacturer unknown) (Lot # not reported), a dose of hepatitis B virus vaccine rHBsAg (yeast) (manufacturer unknown) (Lot # not reported), a dose of pneumococcal vaccine 23 polyvalent (MSD) (Lot # not reported), a dose of tuberculin in purified protein derivative (TUBERSOL) (Lot # not reported), a dose of influenza virus vaccine (FLUZONE) (Lot # not reported) and a dose of meningococcal polysaccharide vaccine (MENOMUME-A/C/Y/W-135) (Lot # UB245AA). Subsequently the patient died on 12/15/2002. It was confirmed that the patient was positive for serogroup C Meningococcal infection. The onset date of signs and symptoms were not reported. An autopsy was performed; however, the results were not available at the time of the report. From additional information received on 08/12/2003 from a pathology department, it was reported that the patient presented with an acute onset of a rash on his feet that spread to his face over a period of a few hours, after a 3 day history of a cough and sore throat. The symptoms progressed rapidly to severe respiratory distress and shock. The patient was treated with advanced cardiac life support in the ICU (intensive care unit) and died within three hours of presenting to the hospital. The patient died at 1:01 pm on 12/15/2002; the autopsy was done the following day and showed that the cause of death was Neisseria Meningitidis Septicemia (Meningococcemia). Gross autopsy findings included evidence acute shock syndrome with diffuse petechia and hemorrhage to multiple organs, visceral congestions, shock kidneys, and a blothcy erythematous rash to the organs and a few scattered foci of acute inflammation within the myocardium and meninges. The clinical presentation, autopsy findings, and laboratory PCR results were consistent with Neisseria Meningitidis (meningococcal) Septicemia (special pathogens branch # M10158). The manner of death was natural. The CDC confirmed that the patient was positive for serogroup C Meningococcal infection. Final anatomical diagnosis from the autopsy report included: Diffuse discrete petechiae and small hemorrhages involving multiple organs, serosa and mucosal surfaces (intestines, mesentery, epicardium, myocardium, renal cortex, adrenals, lungs, pharynx, bronchi, skeletal muscle and conjuctica), pulmonary edema and visceral congestion, bilateral pleural and pericardial effusions, blotchy erythematous rash on face, trunk, arms and legs, shock kidneys with diffuse pale cortices. there was no purulent meningeal exudates present. The PCR results were positive for Neisseria Meningitidis Serogroup C. Microscopic findings included: Numerous fibrin micro thrombi in heart, lungs, liver, glomeruli, brain and oropharynx and scattered small foci of acute inflammation in meninges and myocardium associated with hemorrhage and focal myocyte necrosis. Microscopic descriptions included: Trachea-diffuse mucosal and submucosal hemorrhage without inflammation. Lung-diffuse alveolar damage with numerous scattered fibrin and conspicous granulocytes present in red pulp. Liver-sinusoidal congestion with sinusoids distended by granulocytes and scattered fibrin micro thrombi. Prostate and bladder-mucosal and glandular autolysis, no pathologic diagnosis. There were no radiographs taken. Toxicology results included: Volatiles-the blood and vitereous fluid were examined for the presence of ethanol at a cutoff of 20 mg/dl. No ethanol was detected. The following drugs were detected: Positive Lidocaine-Lidocaine was detected in the liver by gas chromatography and confirmed by gas chromatography/mass spectrometry. Positive Atropine-Atropine was detected in the liver by gas chromatography/mass.


Changed on 9/14/2018

VAERS ID: 207834 Before After
VAERS Form:1
Age:18.0
Sex:Male
Location:California
Vaccinated:2002-11-14
Onset:0000-00-00
Submitted:2003-08-11
Entered:2003-08-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR - / UNK - / -
HEP: HEP B (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK - / -
HEPA: HEP A (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK - / -
MEN: MENINGOCOCCAL (MENOMUNE) / SANOFI PASTEUR UB245AA / UNK - / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. - / UNK - / -
PPV: PNEUMO (PNEUMOVAX) / MERCK & CO. INC. - / UNK - / -

Administered by: Military      Purchased by: Unknown
Symptoms: Cough, Drug ineffective, Dyspnoea, Laboratory test abnormal, Pharyngitis, Rash maculo-papular, Respiratory distress, Sepsis, Shock, Bacterial infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2002-12-15
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: PPD
Current Illness:
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Diagnostic Laboratory: PCR was positive for Neisseria Meningococcal infection serogroup C.
CDC 'Split Type': 200301574

Write-up: From initial information received on 8/7/03 from a medical professional, regarding an adverse event occurring in the US, it was reported that an 18year old male patient received MENOMUNE, lot number UB245AA, FLUZONE (lot number not reported), TUBERSOL (lot number not reported), HEPATITIS A VACCINE (lot number and manufacturer not reported, HEPATITIS B VACCINE (lot number and manufacturer not reported), MMR (lot number not reported), and PNEUMOVAX (lot number not reported) administered on 11/14/02. All vaccines were administered on the same date. The patient died on 12/15/02. The CDC investigation confirmed that the patient was positive for serogroup C, Meningococcal infection. The onset date of signs and symptoms were not reported. An autopsy was performed, however, results were not available at the time of this report. Follow-up information: Information has been received from a health professional concerning an 18 year old male patient who was healthy with no adverse entry who on 11/14/2002 was vaccinated with a dose of MMRII (Lot # not reported). Concomitant therapy on 11/14/2002 included a dose of hepatitis A vaccine (inactive) (manufacturer unknown) (Lot # not reported), a dose of hepatitis B virus vaccine rHBsAg (yeast) (manufacturer unknown) (Lot # not reported), a dose of pneumococcal vaccine 23 polyvalent (MSD) (Lot # not reported), a dose of tuberculin in purified protein derivative (TUBERSOL) (Lot # not reported), a dose of influenza virus vaccine (FLUZONE) (Lot # not reported) and a dose of meningococcal polysaccharide vaccine (MENOMUME-A/C/Y/W-135) (Lot # UB245AA). Subsequently the patient died on 12/15/2002. It was confirmed that the patient was positive for serogroup C Meningococcal infection. The onset date of signs and symptoms were not reported. An autopsy was performed; however, the results were not available at the time of the report. From additional information received on 08/12/2003 from a pathology department, it was reported that the patient presented with an acute onset of a rash on his feet that spread to his face over a period of a few hours, after a 3 day history of a cough and sore throat. The symptoms progressed rapidly to severe respiratory distress and shock. The patient was treated with advanced cardiac life support in the ICU (intensive care unit) and died within three hours of presenting to the hospital. The patient died at 1:01 pm on 12/15/2002; the autopsy was done the following day and showed that the cause of death was Neisseria Meningitidis Septicemia (Meningococcemia). Gross autopsy findings included evidence acute shock syndrome with diffuse petechia and hemorrhage to multiple organs, visceral congestions, shock kidneys, and a blothcy erythematous rash to the organs and a few scattered foci of acute inflammation within the myocardium and meninges. The clinical presentation, autopsy findings, and laboratory PCR results were consistent with Neisseria Meningitidis (meningococcal) Septicemia (special pathogens branch # M10158). The manner of death was natural. The CDC confirmed that the patient was positive for serogroup C Meningococcal infection. Final anatomical diagnosis from the autopsy report included: Diffuse discrete petechiae and small hemorrhages involving multiple organs, serosa and mucosal surfaces (intestines, mesentery, epicardium, myocardium, renal cortex, adrenals, lungs, pharynx, bronchi, skeletal muscle and conjuctica), pulmonary edema and visceral congestion, bilateral pleural and pericardial effusions, blotchy erythematous rash on face, trunk, arms and legs, shock kidneys with diffuse pale cortices. there was no purulent meningeal exudates present. The PCR results were positive for Neisseria Meningitidis Serogroup C. Microscopic findings included: Numerous fibrin micro thrombi in heart, lungs, liver, glomeruli, brain and oropharynx and scattered small foci of acute inflammation in meninges and myocardium associated with hemorrhage and focal myocyte necrosis. Microscopic descriptions included: Trachea-diffuse mucosal and submucosal hemorrhage without inflammation. Lung-diffuse alveolar damage with numerous scattered fibrin and conspicous granulocytes present in red pulp. Liver-sinusoidal congestion with sinusoids distended by granulocytes and scattered fibrin micro thrombi. Prostate and bladder-mucosal and glandular autolysis, no pathologic diagnosis. There were no radiographs taken. Toxicology results included: Volatiles-the blood and vitereous fluid were examined for the presence of ethanol at a cutoff of 20 mg/dl. No ethanol was detected. The following drugs were detected: Positive Lidocaine-Lidocaine was detected in the liver by gas chromatography and confirmed by gas chromatography/mass spectrometry. Positive Atropine-Atropine was detected in the liver by gas chromatography/mass.


Changed on 10/14/2018

VAERS ID: 207834 Before After
VAERS Form:1
Age:18.0
Sex:Male
Location:California
Vaccinated:2002-11-14
Onset:0000-00-00
Submitted:2003-08-11
Entered:2003-08-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR - / UNK - / -
HEP: HEP B (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK - / -
HEPA: HEP A (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK - / -
MEN: MENINGOCOCCAL (MENOMUNE) / SANOFI PASTEUR UB245AA / UNK - / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. - / UNK - / -
PPV: PNEUMO (PNEUMOVAX) / MERCK & CO. INC. - / UNK - / -

Administered by: Military      Purchased by: Unknown
Symptoms: Cough, Drug ineffective, Dyspnoea, Laboratory test abnormal, Pharyngitis, Rash maculo-papular, Respiratory distress, Sepsis, Shock, Bacterial infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2002-12-15
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: PPD
Current Illness:
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Diagnostic Laboratory: PCR was positive for Neisseria Meningococcal infection serogroup C.
CDC 'Split Type': 200301574

Write-up: From initial information received on 8/7/03 from a medical professional, regarding an adverse event occurring in the US, it was reported that an 18year old male patient received MENOMUNE, lot number UB245AA, FLUZONE (lot number not reported), TUBERSOL (lot number not reported), HEPATITIS A VACCINE (lot number and manufacturer not reported, HEPATITIS B VACCINE (lot number and manufacturer not reported), MMR (lot number not reported), and PNEUMOVAX (lot number not reported) administered on 11/14/02. All vaccines were administered on the same date. The patient died on 12/15/02. The CDC investigation confirmed that the patient was positive for serogroup C, Meningococcal infection. The onset date of signs and symptoms were not reported. An autopsy was performed, however, results were not available at the time of this report. Follow-up information: Information has been received from a health professional concerning an 18 year old male patient who was healthy with no adverse entry who on 11/14/2002 was vaccinated with a dose of MMRII (Lot # not reported). Concomitant therapy on 11/14/2002 included a dose of hepatitis A vaccine (inactive) (manufacturer unknown) (Lot # not reported), a dose of hepatitis B virus vaccine rHBsAg (yeast) (manufacturer unknown) (Lot # not reported), a dose of pneumococcal vaccine 23 polyvalent (MSD) (Lot # not reported), a dose of tuberculin in purified protein derivative (TUBERSOL) (Lot # not reported), a dose of influenza virus vaccine (FLUZONE) (Lot # not reported) and a dose of meningococcal polysaccharide vaccine (MENOMUME-A/C/Y/W-135) (Lot # UB245AA). Subsequently the patient died on 12/15/2002. It was confirmed that the patient was positive for serogroup C Meningococcal infection. The onset date of signs and symptoms were not reported. An autopsy was performed; however, the results were not available at the time of the report. From additional information received on 08/12/2003 from a pathology department, it was reported that the patient presented with an acute onset of a rash on his feet that spread to his face over a period of a few hours, after a 3 day history of a cough and sore throat. The symptoms progressed rapidly to severe respiratory distress and shock. The patient was treated with advanced cardiac life support in the ICU (intensive care unit) and died within three hours of presenting to the hospital. The patient died at 1:01 pm on 12/15/2002; the autopsy was done the following day and showed that the cause of death was Neisseria Meningitidis Septicemia (Meningococcemia). Gross autopsy findings included evidence acute shock syndrome with diffuse petechia and hemorrhage to multiple organs, visceral congestions, shock kidneys, and a blothcy erythematous rash to the organs and a few scattered foci of acute inflammation within the myocardium and meninges. The clinical presentation, autopsy findings, and laboratory PCR results were consistent with Neisseria Meningitidis (meningococcal) Septicemia (special pathogens branch # M10158). The manner of death was natural. The CDC confirmed that the patient was positive for serogroup C Meningococcal infection. Final anatomical diagnosis from the autopsy report included: Diffuse discrete petechiae and small hemorrhages involving multiple organs, serosa and mucosal surfaces (intestines, mesentery, epicardium, myocardium, renal cortex, adrenals, lungs, pharynx, bronchi, skeletal muscle and conjuctica), pulmonary edema and visceral congestion, bilateral pleural and pericardial effusions, blotchy erythematous rash on face, trunk, arms and legs, shock kidneys with diffuse pale cortices. there was no purulent meningeal exudates present. The PCR results were positive for Neisseria Meningitidis Serogroup C. Microscopic findings included: Numerous fibrin micro thrombi in heart, lungs, liver, glomeruli, brain and oropharynx and scattered small foci of acute inflammation in meninges and myocardium associated with hemorrhage and focal myocyte necrosis. Microscopic descriptions included: Trachea-diffuse mucosal and submucosal hemorrhage without inflammation. Lung-diffuse alveolar damage with numerous scattered fibrin and conspicous granulocytes present in red pulp. Liver-sinusoidal congestion with sinusoids distended by granulocytes and scattered fibrin micro thrombi. Prostate and bladder-mucosal and glandular autolysis, no pathologic diagnosis. There were no radiographs taken. Toxicology results included: Volatiles-the blood and vitereous fluid were examined for the presence of ethanol at a cutoff of 20 mg/dl. No ethanol was detected. The following drugs were detected: Positive Lidocaine-Lidocaine was detected in the liver by gas chromatography and confirmed by gas chromatography/mass spectrometry. Positive Atropine-Atropine was detected in the liver by gas chromatography/mass.

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