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This is VAERS ID 266239

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History of Changes from the VAERS Wayback Machine

First Appeared on 12/30/2006

VAERS ID: 266239
VAERS Form:
Age:0.2
Sex:Male
Location:California
Vaccinated:2006-10-17
Onset:0000-00-00
Submitted:2006-11-07
Entered:2006-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP HEPB IPV (PEDIARIX) / GLAXOSMITHKLINE AC21B065AA / 0 RL / IM
HIBV: HIB (ACTHIB) / AVENTIS PASTEUR, INC. UE009AB / 0 RL / IM
PNC: PNEUMO, 7-VALENT (PREVNAR) / LEDERLE LABORATORIES B08653R / 0 LL / IM
ROTHB5: ROTAVIRUS VACCINE, LIVE, ORAL, PENTAVALENT (ROTATEQ) / MERCK & CO. INC. 0776F / 0 - / PO

Administered by: Other      Purchased by: Unknown
Symptoms: Diarrhoea, Vomiting

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2006-10-23
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: NONE
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: On call doctor was called on 10/23/06 that the pt was brought to ER (hospital) and pt was dead already. History of diarrhea and vomiting.


Changed on 12/8/2009

VAERS ID: 266239 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:California
Vaccinated:2006-10-17
Onset:0000-00-00
Submitted:2006-11-07
Entered:2006-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP HEPB IPV (PEDIARIX) / GLAXOSMITHKLINE AC21B065AA / 0 RL / IM
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B065AA / 0 RL / IM
HIBV: HIB (ACTHIB) / AVENTIS PASTEUR, INC. SANOFI PASTEUR UE009AB / 0 RL / IM
PNC: PNEUMO, 7-VALENT (PREVNAR) PNEUMO (PREVNAR) / LEDERLE LABORATORIES WYETH PHARMACEUTICALS, INC B08653R / 0 LL / IM
ROTHB5: ROTAVIRUS VACCINE, LIVE, ORAL, PENTAVALENT (ROTATEQ) ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0776F / 0 - / PO

Administered by: Other      Purchased by: Unknown Other
Symptoms: Dehydration, Diarrhoea, Gastroenteritis, Vomiting, Maternal condition affecting foetus

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2006-10-23
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: NONE
Current Illness:
Preexisting Conditions: Birth HX: Birth: 8 lbs, 12 oz, ht 21, head circ 16. Noted to have a rash on initial exam. Dx Infant dermatitis & treated. OB/GYN of mother records from pcp reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep.
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: On call doctor was called on 10/23/06 that the pt was brought to ER (hospital) and pt was dead already. History of diarrhea and vomiting. 11/14/06 Received medical records from PCP including med record from OB/GYN of mother which reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep. Developed thrush on 8/25/06 visit & treated. On 10/17 date of vax visit weight was 12 lbs 9 oz, length 23, head 15.5. Child was noted to be healthy at that time. 6/12/07 Received autopsy report which reveals COD as dehydration due to gastroenteritis & manner of death as natural. Dehydration from severe diarrhea was contributing factor. Parent reported patient had been vomiting along w/diarrhea since 10/21 (received vaccines on 10/17). Parent also admitted to use of drugs (crank) up until her 5th month of pregnancy when prenatal care began. Parent reported that allergy to formula may have been contributory as patient was on his 3rd type of formula. Coroner investigation reveals no milk allergy was reported in pcp medical records.


Changed on 3/2/2010

VAERS ID: 266239 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:California
Vaccinated:2006-10-17
Onset:0000-00-00
Submitted:2006-11-07
Entered:2006-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B065AA / 0 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UE009AB / 0 RL / IM
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC B08653R / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0776F / 0 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Dehydration, Diarrhoea, Gastroenteritis, Vomiting, Maternal condition affecting foetus

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2006-10-23
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: NONE
Current Illness:
Preexisting Conditions: Birth HX: Birth: 8 lbs, 12 oz, ht 21, head circ 16. Noted to have a rash on initial exam. Dx Infant dermatitis & treated. OB/GYN of mother records from pcp reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep.
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: On call doctor was called on 10/23/06 that the pt was brought to ER (hospital) and pt was dead already. History of diarrhea and vomiting. 11/14/06 Received medical records from PCP including med record from OB/GYN of mother which reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep. Developed thrush on 8/25/06 visit & treated. On 10/17 date of vax visit weight was 12 lbs 9 oz, length 23, head 15.5. Child was noted to be healthy at that time. 6/12/07 Received autopsy report which reveals COD as dehydration due to gastroenteritis & manner of death as natural. Dehydration from severe diarrhea was contributing factor. Parent reported patient had been vomiting along w/diarrhea since 10/21 (received vaccines on 10/17). Parent also admitted to use of drugs (crank) up until her 5th month of pregnancy when prenatal care began. Parent reported that allergy to formula may have been contributory as patient was on his 3rd type of formula. Coroner investigation reveals no milk allergy was reported in pcp medical records.


Changed on 4/7/2010

VAERS ID: 266239 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:California
Vaccinated:2006-10-17
Onset:0000-00-00
Submitted:2006-11-07
Entered:2006-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B065AA / 0 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UE009AB / 0 RL / IM
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B08653R / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0776F / 0 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Dehydration, Diarrhoea, Gastroenteritis, Vomiting, Maternal condition affecting foetus

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2006-10-23
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: NONE
Current Illness:
Preexisting Conditions: Birth HX: Birth: 8 lbs, 12 oz, ht 21, head circ 16. Noted to have a rash on initial exam. Dx Infant dermatitis & treated. OB/GYN of mother records from pcp reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep.
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: On call doctor was called on 10/23/06 that the pt was brought to ER (hospital) and pt was dead already. History of diarrhea and vomiting. 11/14/06 Received medical records from PCP including med record from OB/GYN of mother which reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep. Developed thrush on 8/25/06 visit & treated. On 10/17 date of vax visit weight was 12 lbs 9 oz, length 23, head 15.5. Child was noted to be healthy at that time. 6/12/07 Received autopsy report which reveals COD as dehydration due to gastroenteritis & manner of death as natural. Dehydration from severe diarrhea was contributing factor. Parent reported patient had been vomiting along w/diarrhea since 10/21 (received vaccines on 10/17). Parent also admitted to use of drugs (crank) up until her 5th month of pregnancy when prenatal care began. Parent reported that allergy to formula may have been contributory as patient was on his 3rd type of formula. Coroner investigation reveals no milk allergy was reported in pcp medical records.


Changed on 8/31/2010

VAERS ID: 266239 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:California
Vaccinated:2006-10-17
Onset:0000-00-00
Submitted:2006-11-07
Entered:2006-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B065AA / 0 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UE009AB / 0 RL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH B08653R / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0776F / 0 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Dehydration, Diarrhoea, Gastroenteritis, Vomiting, Maternal condition affecting foetus

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2006-10-23
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: NONE
Current Illness:
Preexisting Conditions: Birth HX: Birth: 8 lbs, 12 oz, ht 21, head circ 16. Noted to have a rash on initial exam. Dx Infant dermatitis & treated. OB/GYN of mother records from pcp reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep.
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: On call doctor was called on 10/23/06 that the pt was brought to ER (hospital) and pt was dead already. History of diarrhea and vomiting. 11/14/06 Received medical records from PCP including med record from OB/GYN of mother which reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep. Developed thrush on 8/25/06 visit & treated. On 10/17 date of vax visit weight was 12 lbs 9 oz, length 23, head 15.5. Child was noted to be healthy at that time. 6/12/07 Received autopsy report which reveals COD as dehydration due to gastroenteritis & manner of death as natural. Dehydration from severe diarrhea was contributing factor. Parent reported patient had been vomiting along w/diarrhea since 10/21 (received vaccines on 10/17). Parent also admitted to use of drugs (crank) up until her 5th month of pregnancy when prenatal care began. Parent reported that allergy to formula may have been contributory as patient was on his 3rd type of formula. Coroner investigation reveals no milk allergy was reported in pcp medical records.


Changed on 4/13/2011

VAERS ID: 266239 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:California
Vaccinated:2006-10-17
Onset:0000-00-00
Submitted:2006-11-07
Entered:2006-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B065AA / 0 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UE009AB / 0 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08653R / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0776F / 0 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Dehydration, Diarrhoea, Gastroenteritis, Vomiting, Maternal condition affecting foetus

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2006-10-23
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: NONE
Current Illness:
Preexisting Conditions: Birth HX: Birth: 8 lbs, 12 oz, ht 21, head circ 16. Noted to have a rash on initial exam. Dx Infant dermatitis & treated. OB/GYN of mother records from pcp reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep.
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: On call doctor was called on 10/23/06 that the pt was brought to ER (hospital) and pt was dead already. History of diarrhea and vomiting. 11/14/06 Received medical records from PCP including med record from OB/GYN of mother which reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep. Developed thrush on 8/25/06 visit & treated. On 10/17 date of vax visit weight was 12 lbs 9 oz, length 23, head 15.5. Child was noted to be healthy at that time. 6/12/07 Received autopsy report which reveals COD as dehydration due to gastroenteritis & manner of death as natural. Dehydration from severe diarrhea was contributing factor. Parent reported patient had been vomiting along w/diarrhea since 10/21 (received vaccines on 10/17). Parent also admitted to use of drugs (crank) up until her 5th month of pregnancy when prenatal care began. Parent reported that allergy to formula may have been contributory as patient was on his 3rd type of formula. Coroner investigation reveals no milk allergy was reported in pcp medical records.


Changed on 5/13/2011

VAERS ID: 266239 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:California
Vaccinated:2006-10-17
Onset:0000-00-00
Submitted:2006-11-07
Entered:2006-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B065AA / 0 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UE009AB / 0 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08653R / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0776F / 0 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Dehydration, Diarrhoea, Gastroenteritis, Vomiting, Maternal condition affecting foetus

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2006-10-23
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: NONE
Current Illness:
Preexisting Conditions: Birth HX: Birth: 8 lbs, 12 oz, ht 21, head circ 16. Noted to have a rash on initial exam. Dx Infant dermatitis & treated. OB/GYN of mother records from pcp reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep.
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: On call doctor was called on 10/23/06 that the pt was brought to ER (hospital) and pt was dead already. History of diarrhea and vomiting. 11/14/06 Received medical records from PCP including med record from OB/GYN of mother which reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep. Developed thrush on 8/25/06 visit & treated. On 10/17 date of vax visit weight was 12 lbs 9 oz, length 23, head 15.5. Child was noted to be healthy at that time. 6/12/07 Received autopsy report which reveals COD as dehydration due to gastroenteritis & manner of death as natural. Dehydration from severe diarrhea was contributing factor. Parent reported patient had been vomiting along w/diarrhea since 10/21 (received vaccines on 10/17). Parent also admitted to use of drugs (crank) up until her 5th month of pregnancy when prenatal care began. Parent reported that allergy to formula may have been contributory as patient was on his 3rd type of formula. Coroner investigation reveals no milk allergy was reported in pcp medical records.


Changed on 6/11/2011

VAERS ID: 266239 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:California
Vaccinated:2006-10-17
Onset:0000-00-00
Submitted:2006-11-07
Entered:2006-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B065AA / 0 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UE009AB / 0 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08653R / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0776F / 0 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Dehydration, Diarrhoea, Gastroenteritis, Vomiting, Maternal condition affecting foetus

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2006-10-23
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: NONE
Current Illness:
Preexisting Conditions: Birth HX: Birth: 8 lbs, 12 oz, ht 21, head circ 16. Noted to have a rash on initial exam. Dx Infant dermatitis & treated. OB/GYN of mother records from pcp reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep.
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: On call doctor was called on 10/23/06 that the pt was brought to ER (hospital) and pt was dead already. History of diarrhea and vomiting. 11/14/06 Received medical records from PCP including med record from OB/GYN of mother which reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep. Developed thrush on 8/25/06 visit & treated. On 10/17 date of vax visit weight was 12 lbs 9 oz, length 23, head 15.5. Child was noted to be healthy at that time. 6/12/07 Received autopsy report which reveals COD as dehydration due to gastroenteritis & manner of death as natural. Dehydration from severe diarrhea was contributing factor. Parent reported patient had been vomiting along w/diarrhea since 10/21 (received vaccines on 10/17). Parent also admitted to use of drugs (crank) up until her 5th month of pregnancy when prenatal care began. Parent reported that allergy to formula may have been contributory as patient was on his 3rd type of formula. Coroner investigation reveals no milk allergy was reported in pcp medical records.


Changed on 5/13/2013

VAERS ID: 266239 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:California
Vaccinated:2006-10-17
Onset:0000-00-00
Submitted:2006-11-07
Entered:2006-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B065AA / 0 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UE009AB / 0 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08653R / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0776F / 0 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0776F / 0 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Dehydration, Diarrhoea, Gastroenteritis, Vomiting, Maternal condition affecting foetus

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2006-10-23
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: NONE
Current Illness:
Preexisting Conditions: Birth HX: Birth: 8 lbs, 12 oz, ht 21, head circ 16. Noted to have a rash on initial exam. Dx Infant dermatitis & treated. OB/GYN of mother records from pcp reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep.
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: On call doctor was called on 10/23/06 that the pt was brought to ER (hospital) and pt was dead already. History of diarrhea and vomiting. 11/14/06 Received medical records from PCP including med record from OB/GYN of mother which reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep. Developed thrush on 8/25/06 visit & treated. On 10/17 date of vax visit weight was 12 lbs 9 oz, length 23, head 15.5. Child was noted to be healthy at that time. 6/12/07 Received autopsy report which reveals COD as dehydration due to gastroenteritis & manner of death as natural. Dehydration from severe diarrhea was contributing factor. Parent reported patient had been vomiting along w/diarrhea since 10/21 (received vaccines on 10/17). Parent also admitted to use of drugs (crank) up until her 5th month of pregnancy when prenatal care began. Parent reported that allergy to formula may have been contributory as patient was on his 3rd type of formula. Coroner investigation reveals no milk allergy was reported in pcp medical records.


Changed on 5/14/2017

VAERS ID: 266239 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:California
Vaccinated:2006-10-17
Onset:0000-00-00
Submitted:2006-11-07
Entered:2006-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B065AA / 0 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UE009AB / 0 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08653R / 0 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0776F / 0 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Dehydration, Diarrhoea, Gastroenteritis, Vomiting, Maternal condition affecting foetus

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2006-10-23
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: NONE
Current Illness:
Preexisting Conditions: Birth HX: Birth: 8 lbs, 12 oz, ht 21, head circ 16. Noted to have a rash on initial exam. Dx Infant dermatitis & treated. OB/GYN of mother records from pcp reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep.
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: On call doctor was called on 10/23/06 that the pt was brought to ER (hospital) and pt was dead already. History of diarrhea and vomiting. 11/14/06 Received medical records from PCP including med record from OB/GYN of mother which reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep. Developed thrush on 8/25/06 visit & treated. On 10/17 date of vax visit weight was 12 lbs 9 oz, length 23, head 15.5. Child was noted to be healthy at that time. 6/12/07 Received autopsy report which reveals COD as dehydration due to gastroenteritis & manner of death as natural. Dehydration from severe diarrhea was contributing factor. Parent reported patient had been vomiting along w/diarrhea since 10/21 (received vaccines on 10/17). Parent also admitted to use of drugs (crank) up until her 5th month of pregnancy when prenatal care began. Parent reported that allergy to formula may have been contributory as patient was on his 3rd type of formula. Coroner investigation reveals no milk allergy was reported in pcp medical records.


Changed on 9/14/2017

VAERS ID: 266239 Before After
VAERS Form:(blank) 1
Age:0.2
Sex:Male
Location:California
Vaccinated:2006-10-17
Onset:0000-00-00
Submitted:2006-11-07
Entered:2006-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B065AA / 0 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UE009AB / 0 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08653R / 0 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0776F / 0 1 - MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Diarrhoea, Vomiting

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2006-10-23
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: NONE
Current Illness:
Preexisting Conditions: Birth HX: Birth: 8 lbs, 12 oz, ht 21, head circ 16. Noted to have a rash on initial exam. Dx Infant dermatitis & treated. OB/GYN of mother records from pcp reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep.
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: On call doctor was called on 10/23/06 that the pt was brought to ER (hospital) and pt was dead already. History of diarrhea and vomiting. 11/14/06 Received medical records from PCP including med record from OB/GYN of mother which reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep. Developed thrush on 8/25/06 visit & treated. On 10/17 date of vax visit weight was 12 lbs 9 oz, length 23, head 15.5. Child was noted to be healthy at that time. 6/12/07 Received autopsy report which reveals COD as dehydration due to gastroenteritis & manner of death as natural. Dehydration from severe diarrhea was contributing factor. Parent reported patient had been vomiting along w/diarrhea since 10/21 (received vaccines on 10/17). Parent also admitted to use of drugs (crank) up until her 5th month of pregnancy when prenatal care began. Parent reported that allergy to formula may have been contributory as patient was on his 3rd type of formula. Coroner investigation reveals no milk allergy was reported in pcp medical records.


Changed on 2/14/2018

VAERS ID: 266239 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:California
Vaccinated:2006-10-17
Onset:0000-00-00
Submitted:2006-11-07
Entered:2006-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B065AA / 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UE009AB / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08653R / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0776F / 1 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Diarrhoea, Vomiting

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2006-10-23
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: NONE
Current Illness:
Preexisting Conditions: Birth HX: Birth: 8 lbs, 12 oz, ht 21, head circ 16. Noted to have a rash on initial exam. Dx Infant dermatitis & treated. OB/GYN of mother records from pcp reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep.
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: On call doctor was called on 10/23/06 that the pt was brought to ER (hospital) and pt was dead already. History of diarrhea and vomiting. 11/14/06 Received medical records from PCP including med record from OB/GYN of mother which reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep. Developed thrush on 8/25/06 visit & treated. On 10/17 date of vax visit weight was 12 lbs 9 oz, length 23, head 15.5. Child was noted to be healthy at that time. 6/12/07 Received autopsy report which reveals COD as dehydration due to gastroenteritis & manner of death as natural. Dehydration from severe diarrhea was contributing factor. Parent reported patient had been vomiting along w/diarrhea since 10/21 (received vaccines on 10/17). Parent also admitted to use of drugs (crank) up until her 5th month of pregnancy when prenatal care began. Parent reported that allergy to formula may have been contributory as patient was on his 3rd type of formula. Coroner investigation reveals no milk allergy was reported in pcp medical records.


Changed on 6/14/2018

VAERS ID: 266239 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:California
Vaccinated:2006-10-17
Onset:0000-00-00
Submitted:2006-11-07
Entered:2006-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B065AA / 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UE009AB / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08653R / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0776F / 1 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Diarrhoea, Vomiting

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2006-10-23
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: NONE
Current Illness:
Preexisting Conditions: Birth HX: Birth: 8 lbs, 12 oz, ht 21, head circ 16. Noted to have a rash on initial exam. Dx Infant dermatitis & treated. OB/GYN of mother records from pcp reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep.
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: On call doctor was called on 10/23/06 that the pt was brought to ER (hospital) and pt was dead already. History of diarrhea and vomiting. 11/14/06 Received medical records from PCP including med record from OB/GYN of mother which reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep. Developed thrush on 8/25/06 visit & treated. On 10/17 date of vax visit weight was 12 lbs 9 oz, length 23, head 15.5. Child was noted to be healthy at that time. 6/12/07 Received autopsy report which reveals COD as dehydration due to gastroenteritis & manner of death as natural. Dehydration from severe diarrhea was contributing factor. Parent reported patient had been vomiting along w/diarrhea since 10/21 (received vaccines on 10/17). Parent also admitted to use of drugs (crank) up until her 5th month of pregnancy when prenatal care began. Parent reported that allergy to formula may have been contributory as patient was on his 3rd type of formula. Coroner investigation reveals no milk allergy was reported in pcp medical records.


Changed on 8/14/2018

VAERS ID: 266239 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:California
Vaccinated:2006-10-17
Onset:0000-00-00
Submitted:2006-11-07
Entered:2006-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B065AA / 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UE009AB / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08653R / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0776F / 1 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Diarrhoea, Vomiting

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2006-10-23
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: NONE
Current Illness:
Preexisting Conditions: Birth HX: Birth: 8 lbs, 12 oz, ht 21, head circ 16. Noted to have a rash on initial exam. Dx Infant dermatitis & treated. OB/GYN of mother records from pcp reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep.
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: On call doctor was called on 10/23/06 that the pt was brought to ER (hospital) and pt was dead already. History of diarrhea and vomiting. 11/14/06 Received medical records from PCP including med record from OB/GYN of mother which reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep. Developed thrush on 8/25/06 visit & treated. On 10/17 date of vax visit weight was 12 lbs 9 oz, length 23, head 15.5. Child was noted to be healthy at that time. 6/12/07 Received autopsy report which reveals COD as dehydration due to gastroenteritis & manner of death as natural. Dehydration from severe diarrhea was contributing factor. Parent reported patient had been vomiting along w/diarrhea since 10/21 (received vaccines on 10/17). Parent also admitted to use of drugs (crank) up until her 5th month of pregnancy when prenatal care began. Parent reported that allergy to formula may have been contributory as patient was on his 3rd type of formula. Coroner investigation reveals no milk allergy was reported in pcp medical records.


Changed on 9/14/2018

VAERS ID: 266239 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:California
Vaccinated:2006-10-17
Onset:0000-00-00
Submitted:2006-11-07
Entered:2006-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B065AA / 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UE009AB / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08653R / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0776F / 1 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Diarrhoea, Vomiting

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2006-10-23
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: NONE
Current Illness:
Preexisting Conditions: Birth HX: Birth: 8 lbs, 12 oz, ht 21, head circ 16. Noted to have a rash on initial exam. Dx Infant dermatitis & treated. OB/GYN of mother records from pcp reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep.
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: On call doctor was called on 10/23/06 that the pt was brought to ER (hospital) and pt was dead already. History of diarrhea and vomiting. 11/14/06 Received medical records from PCP including med record from OB/GYN of mother which reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep. Developed thrush on 8/25/06 visit & treated. On 10/17 date of vax visit weight was 12 lbs 9 oz, length 23, head 15.5. Child was noted to be healthy at that time. 6/12/07 Received autopsy report which reveals COD as dehydration due to gastroenteritis & manner of death as natural. Dehydration from severe diarrhea was contributing factor. Parent reported patient had been vomiting along w/diarrhea since 10/21 (received vaccines on 10/17). Parent also admitted to use of drugs (crank) up until her 5th month of pregnancy when prenatal care began. Parent reported that allergy to formula may have been contributory as patient was on his 3rd type of formula. Coroner investigation reveals no milk allergy was reported in pcp medical records.


Changed on 10/14/2018

VAERS ID: 266239 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:California
Vaccinated:2006-10-17
Onset:0000-00-00
Submitted:2006-11-07
Entered:2006-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B065AA / 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UE009AB / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08653R / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0776F / 1 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Diarrhoea, Vomiting

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2006-10-23
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: NONE
Current Illness:
Preexisting Conditions: Birth HX: Birth: 8 lbs, 12 oz, ht 21, head circ 16. Noted to have a rash on initial exam. Dx Infant dermatitis & treated. OB/GYN of mother records from pcp reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep.
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: On call doctor was called on 10/23/06 that the pt was brought to ER (hospital) and pt was dead already. History of diarrhea and vomiting. 11/14/06 Received medical records from PCP including med record from OB/GYN of mother which reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep. Developed thrush on 8/25/06 visit & treated. On 10/17 date of vax visit weight was 12 lbs 9 oz, length 23, head 15.5. Child was noted to be healthy at that time. 6/12/07 Received autopsy report which reveals COD as dehydration due to gastroenteritis & manner of death as natural. Dehydration from severe diarrhea was contributing factor. Parent reported patient had been vomiting along w/diarrhea since 10/21 (received vaccines on 10/17). Parent also admitted to use of drugs (crank) up until her 5th month of pregnancy when prenatal care began. Parent reported that allergy to formula may have been contributory as patient was on his 3rd type of formula. Coroner investigation reveals no milk allergy was reported in pcp medical records.


Changed on 12/24/2020

VAERS ID: 266239 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:California
Vaccinated:2006-10-17
Onset:0000-00-00
Submitted:2006-11-07
Entered:2006-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B065AA / 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UE009AB / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08653R / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0776F / 1 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Diarrhoea, Vomiting

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2006-10-23
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: NONE
Current Illness:
Preexisting Conditions: Birth HX: Birth: 8 lbs, 12 oz, ht 21, head circ 16. Noted to have a rash on initial exam. Dx Infant dermatitis & treated. OB/GYN of mother records from pcp reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep.
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: On call doctor was called on 10/23/06 that the pt was brought to ER (hospital) and pt was dead already. History of diarrhea and vomiting. 11/14/06 Received medical records from PCP including med record from OB/GYN of mother which reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep. Developed thrush on 8/25/06 visit & treated. On 10/17 date of vax visit weight was 12 lbs 9 oz, length 23, head 15.5. Child was noted to be healthy at that time. 6/12/07 Received autopsy report which reveals COD as dehydration due to gastroenteritis & manner of death as natural. Dehydration from severe diarrhea was contributing factor. Parent reported patient had been vomiting along w/diarrhea since 10/21 (received vaccines on 10/17). Parent also admitted to use of drugs (crank) up until her 5th month of pregnancy when prenatal care began. Parent reported that allergy to formula may have been contributory as patient was on his 3rd type of formula. Coroner investigation reveals no milk allergy was reported in pcp medical records.


Changed on 12/30/2020

VAERS ID: 266239 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:California
Vaccinated:2006-10-17
Onset:0000-00-00
Submitted:2006-11-07
Entered:2006-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B065AA / 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UE009AB / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08653R / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0776F / 1 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Diarrhoea, Vomiting

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2006-10-23
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: NONE
Current Illness:
Preexisting Conditions: Birth HX: Birth: 8 lbs, 12 oz, ht 21, head circ 16. Noted to have a rash on initial exam. Dx Infant dermatitis & treated. OB/GYN of mother records from pcp reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep.
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: On call doctor was called on 10/23/06 that the pt was brought to ER (hospital) and pt was dead already. History of diarrhea and vomiting. 11/14/06 Received medical records from PCP including med record from OB/GYN of mother which reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep. Developed thrush on 8/25/06 visit & treated. On 10/17 date of vax visit weight was 12 lbs 9 oz, length 23, head 15.5. Child was noted to be healthy at that time. 6/12/07 Received autopsy report which reveals COD as dehydration due to gastroenteritis & manner of death as natural. Dehydration from severe diarrhea was contributing factor. Parent reported patient had been vomiting along w/diarrhea since 10/21 (received vaccines on 10/17). Parent also admitted to use of drugs (crank) up until her 5th month of pregnancy when prenatal care began. Parent reported that allergy to formula may have been contributory as patient was on his 3rd type of formula. Coroner investigation reveals no milk allergy was reported in pcp medical records.


Changed on 5/7/2021

VAERS ID: 266239 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:California
Vaccinated:2006-10-17
Onset:0000-00-00
Submitted:2006-11-07
Entered:2006-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B065AA / 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UE009AB / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08653R / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0776F / 1 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Diarrhoea, Vomiting

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2006-10-23
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: NONE
Current Illness:
Preexisting Conditions: Birth HX: Birth: 8 lbs, 12 oz, ht 21, head circ 16. Noted to have a rash on initial exam. Dx Infant dermatitis & treated. OB/GYN of mother records from pcp reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep.
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: On call doctor was called on 10/23/06 that the pt was brought to ER (hospital) and pt was dead already. History of diarrhea and vomiting. 11/14/06 Received medical records from PCP including med record from OB/GYN of mother which reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep. Developed thrush on 8/25/06 visit & treated. On 10/17 date of vax visit weight was 12 lbs 9 oz, length 23, head 15.5. Child was noted to be healthy at that time. 6/12/07 Received autopsy report which reveals COD as dehydration due to gastroenteritis & manner of death as natural. Dehydration from severe diarrhea was contributing factor. Parent reported patient had been vomiting along w/diarrhea since 10/21 (received vaccines on 10/17). Parent also admitted to use of drugs (crank) up until her 5th month of pregnancy when prenatal care began. Parent reported that allergy to formula may have been contributory as patient was on his 3rd type of formula. Coroner investigation reveals no milk allergy was reported in pcp medical records.


Changed on 5/21/2021

VAERS ID: 266239 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:California
Vaccinated:2006-10-17
Onset:0000-00-00
Submitted:2006-11-07
Entered:2006-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B065AA / 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UE009AB / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08653R / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0776F / 1 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Diarrhoea, Vomiting

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2006-10-23
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: NONE
Current Illness:
Preexisting Conditions: Birth HX: Birth: 8 lbs, 12 oz, ht 21, head circ 16. Noted to have a rash on initial exam. Dx Infant dermatitis & treated. OB/GYN of mother records from pcp reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep.
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: On call doctor was called on 10/23/06 that the pt was brought to ER (hospital) and pt was dead already. History of diarrhea and vomiting. 11/14/06 Received medical records from PCP including med record from OB/GYN of mother which reveals Mom was 23yo, g4, p2 with PMH of gonorrhea & chlamydia, HSV I & II, Grp B strep. Developed thrush on 8/25/06 visit & treated. On 10/17 date of vax visit weight was 12 lbs 9 oz, length 23, head 15.5. Child was noted to be healthy at that time. 6/12/07 Received autopsy report which reveals COD as dehydration due to gastroenteritis & manner of death as natural. Dehydration from severe diarrhea was contributing factor. Parent reported patient had been vomiting along w/diarrhea since 10/21 (received vaccines on 10/17). Parent also admitted to use of drugs (crank) up until her 5th month of pregnancy when prenatal care began. Parent reported that allergy to formula may have been contributory as patient was on his 3rd type of formula. Coroner investigation reveals no milk allergy was reported in pcp medical records.

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