| VAERS ID: |
269344 (history) |
| Form: |
Version 1.0 |
| Age: |
0.35 |
| Gender: |
Male |
| Location: |
California |
| Vaccinated: | 2006-11-02 |
| Onset: | 2006-12-08 |
| Days after vaccination: | 36 |
| Submitted: |
2006-12-15 |
| Days after onset: | 7 |
| Entered: |
2006-12-19 |
| Days after submission: | 4 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR |
C2490AA / 2 |
RL / IM |
| HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. |
0268F / 2 |
LL / IM |
| IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR |
Y0991 / 2 |
RL / IM |
| PNC: PNEUMO (PREVNAR) / PFIZER/WYETH |
B08681F / 2 |
LL / IM |
| RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. |
0848F / 2 |
MO / PO |
Administered by: Private Purchased by: Private
Symptoms: Gastrointestinal necrosis,
Intussusception,
Lethargy,
Vomiting
SMQs:, Acute pancreatitis (broad), Gastrointestinal obstruction (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Ischaemic colitis (narrow), Hypoglycaemia (broad)
Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness:
Preexisting Conditions: Hydrocele, cafe on lait macules-multiple (No NF)
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: Vomiting and lethargy, intussusception, required surgery for resection at necrotic bowel. |
