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From the 2/18/2021 release of VAERS data:

This is VAERS ID 25553

Case Details

VAERS ID: 25553 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: Tennessee  
Vaccinated:1990-06-25
Onset:1990-06-27
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 1990-07-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 9J01114 / UNK - / -
OPV: POLIO VIRUS, ORAL (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK - / -

Administered by: Private       Purchased by: Private
Symptoms: Adrenal cortex necrosis, Adrenal haemorrhage, Lung disorder, Neoplasm, Petechiae, Pulmonary oedema, Stupor, Ventricular fibrillation
SMQs:, Torsade de pointes/QT prolongation (broad), Cardiac failure (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypoglycaemia (broad), Non-haematological tumours of unspecified malignancy (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: none
Current Illness: routine well baby checkup given
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt found in crib unresponsive at 09:00 6-27-90; DTP & OPV given on 06-25-90 at 15:00. Pt to ER via ambo, no spontaneous heartbeat, pulse or resp. CPR and defib attempted, could not convert v-fib to NSR. Pupils fixed & unresp. See WORM.


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