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This is VAERS ID 272372

History of Changes from the VAERS Wayback Machine

First Appeared on 12/31/2007

VAERS ID: 272372
VAERS Form:
Age:0.1
Gender:Male
Location:Texas
Vaccinated:2006-12-06
Onset:2007-01-17
Submitted:2007-02-15
Entered:2007-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21BO74BA / 0 RL / IM
HIBV: HIB (ACTHIB) / AVENTIS PASTEUR UF023AA / 0 LL / IM
PNC: PNEUMO (PREVNAR) / LEDERLE LABORATORIES BO8682D / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1113F / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium enema, Blood creatinine decreased, Diarrhoea haemorrhagic, Blood urea nitrogen/creatinine ratio increased, Blood alkaline phosphatase increased

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Labs and UGI on hospitalization
CDC 'Split Type':

Write-up: Vomiting on 01-17-07 with subsequent hospitatlization for intussuception requiring surgical intervention.


Changed on 12/8/2009

VAERS ID: 272372 Before After
VAERS Form:
Age:0.1
Gender:Male
Location:Texas
Vaccinated:2006-12-06
Onset:2007-01-17
Submitted:2007-02-15
Entered:2007-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21BO74BA / 0 RL / IM
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21BO74BA / 0 RL / IM
HIBV: HIB (ACTHIB) / AVENTIS PASTEUR UF023AA / 0 LL / IM
PNC: PNEUMO (PREVNAR) / LEDERLE LABORATORIES BO8682D / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1113F / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium enema, Blood creatinine decreased, Diarrhoea haemorrhagic, Intussusception, Irritability, Surgery, Vomiting, X-ray with contrast upper gastrointestinal tract, Blood urea nitrogen/creatinine ratio increased, Blood alkaline phosphatase increased, Laboratory test

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Labs and UGI on hospitalization LABS: Barium enema attempted to reduce intussusception but was unsuccessful. WBC 15.3, alk phos 293, creatinine 0.2, BUN 14. ratio 70.
CDC 'Split Type':

Write-up: Vomiting on 01-17-07 with subsequent hospitatlization for intussuception requiring surgical intervention. 3/15/07 Received medical records from hospital which reveal patient experienced acute onset irritability, vomiting & bloody diarrhea for 24 hrs prior to admit on 01/17/07. Be enema unsuccessful & patient taken to OR for surgical reduction & appendectomy. Progressed well & was d/c to home on 01/18/07. Final Dx: Intussusception, surgically reduced; appendectomy.


Changed on 1/5/2010

VAERS ID: 272372 Before After
VAERS Form:
Age:0.1 0.2
Gender:Male
Location:Texas
Vaccinated:2006-12-06
Onset:2007-01-17
Submitted:2007-02-15
Entered:2007-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21BO74BA / 0 RL / IM
HIBV: HIB (ACTHIB) / AVENTIS PASTEUR SANOFI PASTEUR UF023AA / 0 LL / IM
PNC: PNEUMO (PREVNAR) / LEDERLE LABORATORIES WYETH PHARMACEUTICALS, INC BO8682D / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1113F / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium enema, Blood creatinine decreased, Diarrhoea haemorrhagic, Intussusception, Irritability, Surgery, Vomiting, X-ray with contrast upper gastrointestinal tract, Blood urea nitrogen/creatinine ratio increased, Blood alkaline phosphatase increased, Laboratory test

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Labs and UGI on hospitalization LABS: Barium enema attempted to reduce intussusception but was unsuccessful. WBC 15.3, alk phos 293, creatinine 0.2, BUN 14. ratio 70.
CDC 'Split Type':

Write-up: Vomiting on 01-17-07 with subsequent hospitatlization for intussuception requiring surgical intervention. 3/15/07 Received medical records from hospital which reveal patient experienced acute onset irritability, vomiting & bloody diarrhea for 24 hrs prior to admit on 01/17/07. Be enema unsuccessful & patient taken to OR for surgical reduction & appendectomy. Progressed well & was d/c to home on 01/18/07. Final Dx: Intussusception, surgically reduced; appendectomy.


Changed on 3/2/2010

VAERS ID: 272372 Before After
VAERS Form:
Age:0.2
Gender:Male
Location:Texas
Vaccinated:2006-12-06
Onset:2007-01-17
Submitted:2007-02-15
Entered:2007-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21BO74BA / 0 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF023AA / 0 LL / IM
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC BO8682D / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1113F / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Intussusception, Surgery, Vomiting, X-ray with contrast upper gastrointestinal tract, Laboratory test

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Labs and UGI on hospitalization LABS: Barium enema attempted to reduce intussusception but was unsuccessful. WBC 15.3, alk phos 293, creatinine 0.2, BUN 14. ratio 70.
CDC 'Split Type':

Write-up: Vomiting on 01-17-07 with subsequent hospitatlization for intussuception requiring surgical intervention. 3/15/07 Received medical records from hospital which reveal patient experienced acute onset irritability, vomiting & bloody diarrhea for 24 hrs prior to admit on 01/17/07. Be enema unsuccessful & patient taken to OR for surgical reduction & appendectomy. Progressed well & was d/c to home on 01/18/07. Final Dx: Intussusception, surgically reduced; appendectomy.


Changed on 4/7/2010

VAERS ID: 272372 Before After
VAERS Form:
Age:0.2
Gender:Male
Location:Texas
Vaccinated:2006-12-06
Onset:2007-01-17
Submitted:2007-02-15
Entered:2007-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21BO74BA / 0 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF023AA / 0 LL / IM
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC BO8682D / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1113F / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Intussusception, Surgery, Vomiting, X-ray with contrast upper gastrointestinal tract, Laboratory test

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Labs and UGI on hospitalization LABS: Barium enema attempted to reduce intussusception but was unsuccessful. WBC 15.3, alk phos 293, creatinine 0.2, BUN 14. ratio 70.
CDC 'Split Type':

Write-up: Vomiting on 01-17-07 with subsequent hospitatlization for intussuception requiring surgical intervention. 3/15/07 Received medical records from hospital which reveal patient experienced acute onset irritability, vomiting & bloody diarrhea for 24 hrs prior to admit on 01/17/07. Be enema unsuccessful & patient taken to OR for surgical reduction & appendectomy. Progressed well & was d/c to home on 01/18/07. Final Dx: Intussusception, surgically reduced; appendectomy.


Changed on 8/31/2010

VAERS ID: 272372 Before After
VAERS Form:
Age:0.2
Gender:Male
Location:Texas
Vaccinated:2006-12-06
Onset:2007-01-17
Submitted:2007-02-15
Entered:2007-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21BO74BA / 0 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF023AA / 0 LL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH BO8682D / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1113F / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Blood creatinine decreased, Intussusception, Surgery, Vomiting, X-ray with contrast upper gastrointestinal tract, Laboratory test

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Labs and UGI on hospitalization LABS: Barium enema attempted to reduce intussusception but was unsuccessful. WBC 15.3, alk phos 293, creatinine 0.2, BUN 14. ratio 70.
CDC 'Split Type':

Write-up: Vomiting on 01-17-07 with subsequent hospitatlization for intussuception requiring surgical intervention. 3/15/07 Received medical records from hospital which reveal patient experienced acute onset irritability, vomiting & bloody diarrhea for 24 hrs prior to admit on 01/17/07. Be enema unsuccessful & patient taken to OR for surgical reduction & appendectomy. Progressed well & was d/c to home on 01/18/07. Final Dx: Intussusception, surgically reduced; appendectomy.


Changed on 1/4/2011

VAERS ID: 272372 Before After
VAERS Form:
Age:0.2
Gender:Male
Location:Texas
Vaccinated:2006-12-06
Onset:2007-01-17
Submitted:2007-02-15
Entered:2007-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21BO74BA / 0 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF023AA / 0 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH BO8682D / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1113F / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Blood creatinine decreased, Intussusception, Surgery, Vomiting, X-ray with contrast upper gastrointestinal tract, Laboratory test

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Labs and UGI on hospitalization LABS: Barium enema attempted to reduce intussusception but was unsuccessful. WBC 15.3, alk phos 293, creatinine 0.2, BUN 14. ratio 70.
CDC 'Split Type':

Write-up: Vomiting on 01-17-07 with subsequent hospitatlization for intussuception requiring surgical intervention. 3/15/07 Received medical records from hospital which reveal patient experienced acute onset irritability, vomiting & bloody diarrhea for 24 hrs prior to admit on 01/17/07. Be enema unsuccessful & patient taken to OR for surgical reduction & appendectomy. Progressed well & was d/c to home on 01/18/07. Final Dx: Intussusception, surgically reduced; appendectomy.


Changed on 4/13/2011

VAERS ID: 272372 Before After
VAERS Form:
Age:0.2
Gender:Male
Location:Texas
Vaccinated:2006-12-06
Onset:2007-01-17
Submitted:2007-02-15
Entered:2007-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21BO74BA / 0 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF023AA / 0 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH BO8682D / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1113F / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium enema, Blood creatinine decreased, Diarrhoea haemorrhagic, Intussusception, Irritability, Surgery, Vomiting, X-ray with contrast upper gastrointestinal tract, Blood urea nitrogen/creatinine ratio increased, Blood alkaline phosphatase increased, Laboratory test

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Labs and UGI on hospitalization LABS: Barium enema attempted to reduce intussusception but was unsuccessful. WBC 15.3, alk phos 293, creatinine 0.2, BUN 14. ratio 70.
CDC 'Split Type':

Write-up: Vomiting on 01-17-07 with subsequent hospitatlization for intussuception requiring surgical intervention. 3/15/07 Received medical records from hospital which reveal patient experienced acute onset irritability, vomiting & bloody diarrhea for 24 hrs prior to admit on 01/17/07. Be enema unsuccessful & patient taken to OR for surgical reduction & appendectomy. Progressed well & was d/c to home on 01/18/07. Final Dx: Intussusception, surgically reduced; appendectomy.


Changed on 5/13/2011

VAERS ID: 272372 Before After
VAERS Form:
Age:0.2
Gender:Male
Location:Texas
Vaccinated:2006-12-06
Onset:2007-01-17
Submitted:2007-02-15
Entered:2007-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21BO74BA / 0 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF023AA / 0 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH BO8682D / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1113F / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium enema, Blood creatinine decreased, Diarrhoea haemorrhagic, Intussusception, Irritability, Surgery, Vomiting, X-ray with contrast upper gastrointestinal tract, Blood urea nitrogen/creatinine ratio increased, Blood alkaline phosphatase increased, Laboratory test

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Labs and UGI on hospitalization LABS: Barium enema attempted to reduce intussusception but was unsuccessful. WBC 15.3, alk phos 293, creatinine 0.2, BUN 14. ratio 70.
CDC 'Split Type':

Write-up: Vomiting on 01-17-07 with subsequent hospitatlization for intussuception requiring surgical intervention. 3/15/07 Received medical records from hospital which reveal patient experienced acute onset irritability, vomiting & bloody diarrhea for 24 hrs prior to admit on 01/17/07. Be enema unsuccessful & patient taken to OR for surgical reduction & appendectomy. Progressed well & was d/c to home on 01/18/07. Final Dx: Intussusception, surgically reduced; appendectomy.


Changed on 6/11/2011

VAERS ID: 272372 Before After
VAERS Form:
Age:0.2
Gender:Male
Location:Texas
Vaccinated:2006-12-06
Onset:2007-01-17
Submitted:2007-02-15
Entered:2007-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21BO74BA / 0 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF023AA / 0 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH BO8682D / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1113F / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium enema, Blood creatinine decreased, Diarrhoea haemorrhagic, Intussusception, Irritability, Surgery, Vomiting, X-ray with contrast upper gastrointestinal tract, Blood urea nitrogen/creatinine ratio increased, Blood alkaline phosphatase increased, Laboratory test

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Labs and UGI on hospitalization LABS: Barium enema attempted to reduce intussusception but was unsuccessful. WBC 15.3, alk phos 293, creatinine 0.2, BUN 14. ratio 70.
CDC 'Split Type':

Write-up: Vomiting on 01-17-07 with subsequent hospitatlization for intussuception requiring surgical intervention. 3/15/07 Received medical records from hospital which reveal patient experienced acute onset irritability, vomiting & bloody diarrhea for 24 hrs prior to admit on 01/17/07. Be enema unsuccessful & patient taken to OR for surgical reduction & appendectomy. Progressed well & was d/c to home on 01/18/07. Final Dx: Intussusception, surgically reduced; appendectomy.


Changed on 5/13/2013

VAERS ID: 272372 Before After
VAERS Form:
Age:0.2
Gender:Male
Location:Texas
Vaccinated:2006-12-06
Onset:2007-01-17
Submitted:2007-02-15
Entered:2007-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21BO74BA / 0 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF023AA / 0 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH BO8682D / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1113F / 0 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1113F / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium enema, Blood creatinine decreased, Diarrhoea haemorrhagic, Intussusception, Irritability, Surgery, Vomiting, X-ray with contrast upper gastrointestinal tract, Blood urea nitrogen/creatinine ratio increased, Blood alkaline phosphatase increased, Laboratory test

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Labs and UGI on hospitalization LABS: Barium enema attempted to reduce intussusception but was unsuccessful. WBC 15.3, alk phos 293, creatinine 0.2, BUN 14. ratio 70.
CDC 'Split Type':

Write-up: Vomiting on 01-17-07 with subsequent hospitatlization for intussuception requiring surgical intervention. 3/15/07 Received medical records from hospital which reveal patient experienced acute onset irritability, vomiting & bloody diarrhea for 24 hrs prior to admit on 01/17/07. Be enema unsuccessful & patient taken to OR for surgical reduction & appendectomy. Progressed well & was d/c to home on 01/18/07. Final Dx: Intussusception, surgically reduced; appendectomy.


Changed on 6/14/2014

VAERS ID: 272372 Before After
VAERS Form:
Age:0.2
Gender:Male
Location:Texas
Vaccinated:2006-12-06
Onset:2007-01-17
Submitted:2007-02-15
Entered:2007-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21BO74BA / 0 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF023AA / 0 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH BO8682D / 0 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1113F / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium enema, Blood creatinine decreased, Diarrhoea haemorrhagic, Intussusception, Irritability, Surgery, Vomiting, X-ray with contrast upper gastrointestinal tract, Blood urea nitrogen/creatinine ratio increased, Blood alkaline phosphatase increased, Laboratory test

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Labs and UGI on hospitalization LABS: Barium enema attempted to reduce intussusception but was unsuccessful. WBC 15.3, alk phos 293, creatinine 0.2, BUN 14. ratio 70.
CDC 'Split Type':

Write-up: Vomiting on 01-17-07 with subsequent hospitatlization for intussuception requiring surgical intervention. 3/15/07 Received medical records from hospital which reveal patient experienced acute onset irritability, vomiting & bloody diarrhea for 24 hrs prior to admit on 01/17/07. Be enema unsuccessful & patient taken to OR for surgical reduction & appendectomy. Progressed well & was d/c to home on 01/18/07. Final Dx: Intussusception, surgically reduced; appendectomy.


Changed on 2/14/2017

VAERS ID: 272372 Before After
VAERS Form:
Age:0.2 0.17
Gender:Male
Location:Texas
Vaccinated:2006-12-06
Onset:2007-01-17
Submitted:2007-02-15
Entered:2007-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21BO74BA / 0 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF023AA / 0 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH BO8682D / 0 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1113F / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium enema, Blood creatinine decreased, Diarrhoea haemorrhagic, Intussusception, Irritability, Surgery, Vomiting, X-ray with contrast upper gastrointestinal tract, Blood urea nitrogen/creatinine ratio increased, Blood alkaline phosphatase increased, Laboratory test

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Labs and UGI on hospitalization LABS: Barium enema attempted to reduce intussusception but was unsuccessful. WBC 15.3, alk phos 293, creatinine 0.2, BUN 14. ratio 70.
CDC 'Split Type':

Write-up: Vomiting on 01-17-07 with subsequent hospitatlization for intussuception requiring surgical intervention. 3/15/07 Received medical records from hospital which reveal patient experienced acute onset irritability, vomiting & bloody diarrhea for 24 hrs prior to admit on 01/17/07. Be enema unsuccessful & patient taken to OR for surgical reduction & appendectomy. Progressed well & was d/c to home on 01/18/07. Final Dx: Intussusception, surgically reduced; appendectomy.


Changed on 5/14/2017

VAERS ID: 272372 Before After
VAERS Form:
Age:0.17
Gender:Male
Location:Texas
Vaccinated:2006-12-06
Onset:2007-01-17
Submitted:2007-02-15
Entered:2007-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21BO74BA / 0 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF023AA / 0 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH BO8682D / 0 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1113F / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium enema, Blood creatinine decreased, Diarrhoea haemorrhagic, Intussusception, Irritability, Surgery, Vomiting, X-ray with contrast upper gastrointestinal tract, Blood urea nitrogen/creatinine ratio increased, Blood alkaline phosphatase increased, Laboratory test

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Labs and UGI on hospitalization LABS: Barium enema attempted to reduce intussusception but was unsuccessful. WBC 15.3, alk phos 293, creatinine 0.2, BUN 14. ratio 70.
CDC 'Split Type':

Write-up: Vomiting on 01-17-07 with subsequent hospitatlization for intussuception requiring surgical intervention. 3/15/07 Received medical records from hospital which reveal patient experienced acute onset irritability, vomiting & bloody diarrhea for 24 hrs prior to admit on 01/17/07. Be enema unsuccessful & patient taken to OR for surgical reduction & appendectomy. Progressed well & was d/c to home on 01/18/07. Final Dx: Intussusception, surgically reduced; appendectomy.


Changed on 9/14/2017

VAERS ID: 272372 Before After
VAERS Form:(blank) 1
Age:0.17
Gender:Male
Location:Texas
Vaccinated:2006-12-06
Onset:2007-01-17
Submitted:2007-02-15
Entered:2007-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21BO74BA / 0 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF023AA / 0 1 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH BO8682D / 0 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1113F / 0 1 - MO / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Intussusception, Surgery, Vomiting, X-ray with contrast upper gastrointestinal tract, Laboratory test

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Labs and UGI on hospitalization LABS: Barium enema attempted to reduce intussusception but was unsuccessful. WBC 15.3, alk phos 293, creatinine 0.2, BUN 14. ratio 70.
CDC 'Split Type':

Write-up: Vomiting on 01-17-07 with subsequent hospitatlization for intussuception requiring surgical intervention. 3/15/07 Received medical records from hospital which reveal patient experienced acute onset irritability, vomiting & bloody diarrhea for 24 hrs prior to admit on 01/17/07. Be enema unsuccessful & patient taken to OR for surgical reduction & appendectomy. Progressed well & was d/c to home on 01/18/07. Final Dx: Intussusception, surgically reduced; appendectomy.


Changed on 2/14/2018

VAERS ID: 272372 Before After
VAERS Form:1
Age:0.17
Gender:Male
Location:Texas
Vaccinated:2006-12-06
Onset:2007-01-17
Submitted:2007-02-15
Entered:2007-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21BO74BA / 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF023AA / 1 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH BO8682D / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1113F / 1 MO / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Intussusception, Surgery, Vomiting, X-ray with contrast upper gastrointestinal tract, Laboratory test

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Labs and UGI on hospitalization LABS: Barium enema attempted to reduce intussusception but was unsuccessful. WBC 15.3, alk phos 293, creatinine 0.2, BUN 14. ratio 70.
CDC 'Split Type':

Write-up: Vomiting on 01-17-07 with subsequent hospitatlization for intussuception requiring surgical intervention. 3/15/07 Received medical records from hospital which reveal patient experienced acute onset irritability, vomiting & bloody diarrhea for 24 hrs prior to admit on 01/17/07. Be enema unsuccessful & patient taken to OR for surgical reduction & appendectomy. Progressed well & was d/c to home on 01/18/07. Final Dx: Intussusception, surgically reduced; appendectomy.


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