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This is VAERS ID 275361

(NOTE: This result is from the 5/13/2013 version of the VAERS database)

Case Details

VAERS ID: 275361 (history)  
Form: Version .0  
Age: 0.4  
Gender: Female  
Location: Unknown  
Vaccinated:2007-01-30
Onset:2007-03-23
   Days after vaccination:52
Submitted: 2007-03-30
   Days after onset:7
Entered: 2007-04-02
   Days after submission:3
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (NO BRAND NAME) / UNKNOWN MANUFACTURER AC14B040CA / 1 - / -
HIBV: HIB (NO BRAND NAME) / UNKNOWN MANUFACTURER 0407F / 1 - / -
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / UNKNOWN MANUFACTURER Z0456 / 1 - / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08670K / 1 - / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1232F / 1 UN / -

Administered by: Other       Purchased by: Other
Symptoms: Abdominal mass, Abdominal rigidity, Agitation, Barium double contrast, Haematochezia, Intussusception, Pyrexia, Ultrasound abdomen, Vomiting projectile
SMQs:, Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Gastrointestinal haemorrhage (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Hostility/aggression (broad), Ischaemic colitis (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, 1 days
   Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Unknown PMH: hospitalization x 2 for RSV 12/06 & 1/07. several episodes of apnea. GERD. premature at 35 wks via c-section. Mother had problems w/prior pregnancies & required steroid injections for spontaneous prior abortions. ALLERGY to lactose.
Allergies:
Diagnostic Lab Data: Unknown LABS: WBC 19.5. US + for IS. Barium air contrast enema.
CDC Split Type: WAES0703USA05137

Write-up: Information has been received from a physician concerning a 6 month old female who on 24-NOV-2006 was vaccinated with her first dose of Rotateq (LOT # not provided). On 30-JAN-2007, she was vaccinated with her second dose of Rotateq (LOT # not provided). On 23-MAR-2007, the patient developed intussusception and was hospitalized. An air contrast enema was performed. Subsequently, the patient recovered from intussusception. The patient sought unspecified medical attention. There was no product quality complaint involved. Additional information has been requested. 4/17/07 Received medical records from hospital which reveal patient experienced fever, fussiness, bloody stools & projectile vomiting. Had recently been treated for otitis media, was awaiting ear tube placement & had yeast infection. Temp on admit was 103.3 RUQ palpable mass noted w/guarding. Admitted 3/24-3/25/07 for observation s/p barium air contrast enema successful reduction of IS. FINAL DX: Intussusception, reduced by barium air contrast enema.


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http://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20130513&IDNUMBER=275361


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