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This is VAERS ID 277125

History of Changes from the VAERS Wayback Machine

First Appeared on 12/31/2007

277125
VAERS Form:
Age:0.3
Gender:Male
Location:Pennsylvania
Vaccinated:2007-02-13
Onset:2007-04-14
Submitted:2007-04-20
Entered:2007-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2553AA / 1 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF064AA / 1 - / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0326 / 1 LL / -
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B36258B / 1 - / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1166F / 1 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Abdominal pain, Appendicectomy, Barium enema, Adenovirus infection, Abdominal X-ray

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit? (V2.0) No
Hospitalized? Yes, days: 4     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: (+) adenovirus PCR
CDC 'Split Type':

Write-up:4/14/07 - Presented with /"coffee ground emesis/" and bloody stools. Mom took him to ER, dx''''d with adenovirus and intussusception. Unable to reduce with barium enema reduced with surgery. S/P Appendectomy.


Changed on 12/8/2009

277125 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Pennsylvania
Vaccinated:2007-02-13
Onset:2007-04-14
Submitted:2007-04-20
Entered:2007-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2553AA / 1 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF064AA / 1 - / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0326 / 1 LL / -
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B36258B / 1 - / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1166F / 1 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Abdominal pain, Appendicectomy, Barium enema, Cough, Diarrhoea, Gastroenteritis, Haematemesis, Haematochezia, Intussusception, Laparoscopy, Rhinorrhoea, Sneezing, Surgery, Vomiting, Polymerase chain reaction, Ultrasound abdomen abnormal, Adenovirus infection, Virus serology test, Abdominal X-ray, Rotavirus test negative

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit? (V2.0) No
Hospitalized? Yes, days: 4     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: (+) adenovirus PCR LABS: nasopharyngeal c/s +adenovirus. Rotavirus antigen neg. Abdominal x-ray revealed possible IS. US of abdomen revealed +IS. Barium enema attempt to reduce IS was unsuccessful.
CDC 'Split Type':

Write-up:4/14/07 - Presented with /"coffee "coffee ground emesis/" emesis" and bloody stools. Mom took him to ER, dx''''d dx''d with adenovirus and intussusception. Unable to reduce with barium enema reduced with surgery. S/P Appendectomy. 6/1/07 Received vax record from PCP which indicates RO Lot # is as reported & was 2nd dose. VAERS database updated w/same. 6/5/07 Received hospital medical records which reveal patient experienced diarrhea x 7 days, bloody mucous x 1 day & abdominal pain. Also w/rhinorrhea, cough & sneeze. Admitted 4/14-4/17/07 for bacterial gastroenteritis. On initial hospital day had coffee ground emesis. Taken to OR for laproscopic reduction of IS & appendectomy. Stable post op FINAL DX: Ileocolic intussusception, surgically reduced; adenovirus.


Changed on 3/2/2010

277125 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Pennsylvania
Vaccinated:2007-02-13
Onset:2007-04-14
Submitted:2007-04-20
Entered:2007-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2553AA / 1 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF064AA / 1 - / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0326 / 1 LL / -
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC B36258B / 1 - / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1166F / 1 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Abdominal pain, Appendicectomy, Barium enema, Cough, Diarrhoea, Gastroenteritis, Haematemesis, Haematochezia, Intussusception, Laparoscopy, Rhinorrhoea, Sneezing, Surgery, Vomiting, Polymerase chain reaction, Ultrasound abdomen abnormal, Adenovirus infection, Virus serology test, Abdominal X-ray, Rotavirus test negative

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit? (V2.0) No
Hospitalized? Yes, days: 4     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: (+) adenovirus PCR LABS: nasopharyngeal c/s +adenovirus. Rotavirus antigen neg. Abdominal x-ray revealed possible IS. US of abdomen revealed +IS. Barium enema attempt to reduce IS was unsuccessful.
CDC 'Split Type':

Write-up:4/14/07 - Presented with "coffee ground emesis" and bloody stools. Mom took him to ER, dx''d with adenovirus and intussusception. Unable to reduce with barium enema reduced with surgery. S/P Appendectomy. 6/1/07 Received vax record from PCP which indicates RO Lot # is as reported & was 2nd dose. VAERS database updated w/same. 6/5/07 Received hospital medical records which reveal patient experienced diarrhea x 7 days, bloody mucous x 1 day & abdominal pain. Also w/rhinorrhea, cough & sneeze. Admitted 4/14-4/17/07 for bacterial gastroenteritis. On initial hospital day had coffee ground emesis. Taken to OR for laproscopic reduction of IS & appendectomy. Stable post op FINAL DX: Ileocolic intussusception, surgically reduced; adenovirus.


Changed on 4/7/2010

277125 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Pennsylvania
Vaccinated:2007-02-13
Onset:2007-04-14
Submitted:2007-04-20
Entered:2007-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2553AA / 1 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF064AA / 1 - / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0326 / 1 LL / -
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B36258B / 1 - / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1166F / 1 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Abdominal pain, Appendicectomy, Barium enema, Cough, Diarrhoea, Gastroenteritis, Haematemesis, Haematochezia, Intussusception, Laparoscopy, Rhinorrhoea, Sneezing, Surgery, Vomiting, Polymerase chain reaction, Ultrasound abdomen abnormal, Adenovirus infection, Virus serology test, Abdominal X-ray, Rotavirus test negative

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit? (V2.0) No
Hospitalized? Yes, days: 4     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: (+) adenovirus PCR LABS: nasopharyngeal c/s +adenovirus. Rotavirus antigen neg. Abdominal x-ray revealed possible IS. US of abdomen revealed +IS. Barium enema attempt to reduce IS was unsuccessful.
CDC 'Split Type':

Write-up:4/14/07 - Presented with "coffee ground emesis" and bloody stools. Mom took him to ER, dx''d with adenovirus and intussusception. Unable to reduce with barium enema reduced with surgery. S/P Appendectomy. 6/1/07 Received vax record from PCP which indicates RO Lot # is as reported & was 2nd dose. VAERS database updated w/same. 6/5/07 Received hospital medical records which reveal patient experienced diarrhea x 7 days, bloody mucous x 1 day & abdominal pain. Also w/rhinorrhea, cough & sneeze. Admitted 4/14-4/17/07 for bacterial gastroenteritis. On initial hospital day had coffee ground emesis. Taken to OR for laproscopic reduction of IS & appendectomy. Stable post op FINAL DX: Ileocolic intussusception, surgically reduced; adenovirus.


Changed on 8/31/2010

277125 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Pennsylvania
Vaccinated:2007-02-13
Onset:2007-04-14
Submitted:2007-04-20
Entered:2007-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2553AA / 1 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF064AA / 1 - / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0326 / 1 LL / -
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH B36258B / 1 - / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1166F / 1 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Abdominal pain, Appendicectomy, Barium enema, Cough, Diarrhoea, Gastroenteritis, Haematemesis, Haematochezia, Intussusception, Laparoscopy, Rhinorrhoea, Sneezing, Surgery, Vomiting, Polymerase chain reaction, Ultrasound abdomen abnormal, Adenovirus infection, Virus serology test, Abdominal X-ray, Rotavirus test negative

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit? (V2.0) No
Hospitalized? Yes, days: 4     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: (+) adenovirus PCR LABS: nasopharyngeal c/s +adenovirus. Rotavirus antigen neg. Abdominal x-ray revealed possible IS. US of abdomen revealed +IS. Barium enema attempt to reduce IS was unsuccessful.
CDC 'Split Type':

Write-up:4/14/07 - Presented with "coffee ground emesis" and bloody stools. Mom took him to ER, dx''d with adenovirus and intussusception. Unable to reduce with barium enema reduced with surgery. S/P Appendectomy. 6/1/07 Received vax record from PCP which indicates RO Lot # is as reported & was 2nd dose. VAERS database updated w/same. 6/5/07 Received hospital medical records which reveal patient experienced diarrhea x 7 days, bloody mucous x 1 day & abdominal pain. Also w/rhinorrhea, cough & sneeze. Admitted 4/14-4/17/07 for bacterial gastroenteritis. On initial hospital day had coffee ground emesis. Taken to OR for laproscopic reduction of IS & appendectomy. Stable post op FINAL DX: Ileocolic intussusception, surgically reduced; adenovirus.


Changed on 4/13/2011

277125 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Pennsylvania
Vaccinated:2007-02-13
Onset:2007-04-14
Submitted:2007-04-20
Entered:2007-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2553AA / 1 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF064AA / 1 - / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0326 / 1 LL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B36258B / 1 - / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1166F / 1 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Abdominal pain, Appendicectomy, Barium enema, Cough, Diarrhoea, Gastroenteritis, Haematemesis, Haematochezia, Intussusception, Laparoscopy, Rhinorrhoea, Sneezing, Surgery, Vomiting, Polymerase chain reaction, Ultrasound abdomen abnormal, Adenovirus infection, Virus serology test, Abdominal X-ray, Rotavirus test negative

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit? (V2.0) No
Hospitalized? Yes, days: 4     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: (+) adenovirus PCR LABS: nasopharyngeal c/s +adenovirus. Rotavirus antigen neg. Abdominal x-ray revealed possible IS. US of abdomen revealed +IS. Barium enema attempt to reduce IS was unsuccessful.
CDC 'Split Type':

Write-up:4/14/07 - Presented with "coffee ground emesis" and bloody stools. Mom took him to ER, dx''d with adenovirus and intussusception. Unable to reduce with barium enema reduced with surgery. S/P Appendectomy. 6/1/07 Received vax record from PCP which indicates RO Lot # is as reported & was 2nd dose. VAERS database updated w/same. 6/5/07 Received hospital medical records which reveal patient experienced diarrhea x 7 days, bloody mucous x 1 day & abdominal pain. Also w/rhinorrhea, cough & sneeze. Admitted 4/14-4/17/07 for bacterial gastroenteritis. On initial hospital day had coffee ground emesis. Taken to OR for laproscopic reduction of IS & appendectomy. Stable post op FINAL DX: Ileocolic intussusception, surgically reduced; adenovirus.


Changed on 5/13/2011

277125 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Pennsylvania
Vaccinated:2007-02-13
Onset:2007-04-14
Submitted:2007-04-20
Entered:2007-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2553AA / 1 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF064AA / 1 - / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0326 / 1 LL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B36258B / 1 - / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1166F / 1 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Abdominal pain, Appendicectomy, Barium enema, Cough, Diarrhoea, Gastroenteritis, Haematemesis, Haematochezia, Intussusception, Laparoscopy, Rhinorrhoea, Sneezing, Surgery, Vomiting, Polymerase chain reaction, Ultrasound abdomen abnormal, Adenovirus infection, Virus serology test, Abdominal X-ray, Rotavirus test negative

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit? (V2.0) No
Hospitalized? Yes, days: 4     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: (+) adenovirus PCR LABS: nasopharyngeal c/s +adenovirus. Rotavirus antigen neg. Abdominal x-ray revealed possible IS. US of abdomen revealed +IS. Barium enema attempt to reduce IS was unsuccessful.
CDC 'Split Type':

Write-up:4/14/07 - Presented with "coffee ground emesis" and bloody stools. Mom took him to ER, dx''d with adenovirus and intussusception. Unable to reduce with barium enema reduced with surgery. S/P Appendectomy. 6/1/07 Received vax record from PCP which indicates RO Lot # is as reported & was 2nd dose. VAERS database updated w/same. 6/5/07 Received hospital medical records which reveal patient experienced diarrhea x 7 days, bloody mucous x 1 day & abdominal pain. Also w/rhinorrhea, cough & sneeze. Admitted 4/14-4/17/07 for bacterial gastroenteritis. On initial hospital day had coffee ground emesis. Taken to OR for laproscopic reduction of IS & appendectomy. Stable post op FINAL DX: Ileocolic intussusception, surgically reduced; adenovirus.


Changed on 6/11/2011

277125 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Pennsylvania
Vaccinated:2007-02-13
Onset:2007-04-14
Submitted:2007-04-20
Entered:2007-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2553AA / 1 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF064AA / 1 - / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0326 / 1 LL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B36258B / 1 - / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1166F / 1 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Abdominal pain, Appendicectomy, Barium enema, Cough, Diarrhoea, Gastroenteritis, Haematemesis, Haematochezia, Intussusception, Laparoscopy, Rhinorrhoea, Sneezing, Surgery, Vomiting, Polymerase chain reaction, Ultrasound abdomen abnormal, Adenovirus infection, Virus serology test, Abdominal X-ray, Rotavirus test negative

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit? (V2.0) No
Hospitalized? Yes, days: 4     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: (+) adenovirus PCR LABS: nasopharyngeal c/s +adenovirus. Rotavirus antigen neg. Abdominal x-ray revealed possible IS. US of abdomen revealed +IS. Barium enema attempt to reduce IS was unsuccessful.
CDC 'Split Type':

Write-up:4/14/07 - Presented with "coffee ground emesis" and bloody stools. Mom took him to ER, dx''d with adenovirus and intussusception. Unable to reduce with barium enema reduced with surgery. S/P Appendectomy. 6/1/07 Received vax record from PCP which indicates RO Lot # is as reported & was 2nd dose. VAERS database updated w/same. 6/5/07 Received hospital medical records which reveal patient experienced diarrhea x 7 days, bloody mucous x 1 day & abdominal pain. Also w/rhinorrhea, cough & sneeze. Admitted 4/14-4/17/07 for bacterial gastroenteritis. On initial hospital day had coffee ground emesis. Taken to OR for laproscopic reduction of IS & appendectomy. Stable post op FINAL DX: Ileocolic intussusception, surgically reduced; adenovirus.


Changed on 5/13/2013

277125 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Pennsylvania
Vaccinated:2007-02-13
Onset:2007-04-14
Submitted:2007-04-20
Entered:2007-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2553AA / 1 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF064AA / 1 - / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0326 / 1 LL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B36258B / 1 - / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1166F / 1 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1166F / 1 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Abdominal pain, Appendicectomy, Barium enema, Cough, Diarrhoea, Gastroenteritis, Haematemesis, Haematochezia, Intussusception, Laparoscopy, Rhinorrhoea, Sneezing, Surgery, Vomiting, Polymerase chain reaction, Ultrasound abdomen abnormal, Adenovirus infection, Virus serology test, Abdominal X-ray, Rotavirus test negative

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit? (V2.0) No
Hospitalized? Yes, days: 4     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: (+) adenovirus PCR LABS: nasopharyngeal c/s +adenovirus. Rotavirus antigen neg. Abdominal x-ray revealed possible IS. US of abdomen revealed +IS. Barium enema attempt to reduce IS was unsuccessful.
CDC 'Split Type':

Write-up:4/14/07 - Presented with "coffee ground emesis" and bloody stools. Mom took him to ER, dx''d with adenovirus and intussusception. Unable to reduce with barium enema reduced with surgery. S/P Appendectomy. 6/1/07 Received vax record from PCP which indicates RO Lot # is as reported & was 2nd dose. VAERS database updated w/same. 6/5/07 Received hospital medical records which reveal patient experienced diarrhea x 7 days, bloody mucous x 1 day & abdominal pain. Also w/rhinorrhea, cough & sneeze. Admitted 4/14-4/17/07 for bacterial gastroenteritis. On initial hospital day had coffee ground emesis. Taken to OR for laproscopic reduction of IS & appendectomy. Stable post op FINAL DX: Ileocolic intussusception, surgically reduced; adenovirus.


Changed on 2/14/2017

277125 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Pennsylvania
Vaccinated:2007-02-13
Onset:2007-04-14
Submitted:2007-04-20
Entered:2007-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2553AA / 1 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF064AA / 1 - / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0326 / 1 LL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B36258B / 1 - / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1166F / 1 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Abdominal pain, Appendicectomy, Barium enema, Cough, Diarrhoea, Gastroenteritis, Haematemesis, Haematochezia, Intussusception, Laparoscopy, Rhinorrhoea, Sneezing, Surgery, Vomiting, Polymerase chain reaction, Ultrasound abdomen abnormal, Adenovirus infection, Virus serology test, Abdominal X-ray, Rotavirus test negative

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit? (V2.0) No
Hospitalized? Yes, days: 4     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: (+) adenovirus PCR LABS: nasopharyngeal c/s +adenovirus. Rotavirus antigen neg. Abdominal x-ray revealed possible IS. US of abdomen revealed +IS. Barium enema attempt to reduce IS was unsuccessful.
CDC 'Split Type':

Write-up:4/14/07 - Presented with "coffee ground emesis" and bloody stools. Mom took him to ER, dx''d with adenovirus and intussusception. Unable to reduce with barium enema reduced with surgery. S/P Appendectomy. 6/1/07 Received vax record from PCP which indicates RO Lot # is as reported & was 2nd dose. VAERS database updated w/same. 6/5/07 Received hospital medical records which reveal patient experienced diarrhea x 7 days, bloody mucous x 1 day & abdominal pain. Also w/rhinorrhea, cough & sneeze. Admitted 4/14-4/17/07 for bacterial gastroenteritis. On initial hospital day had coffee ground emesis. Taken to OR for laproscopic reduction of IS & appendectomy. Stable post op FINAL DX: Ileocolic intussusception, surgically reduced; adenovirus.


Changed on 9/14/2017

277125 Before After
VAERS Form:(blank) 1
Age:0.3
Gender:Male
Location:Pennsylvania
Vaccinated:2007-02-13
Onset:2007-04-14
Submitted:2007-04-20
Entered:2007-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2553AA / 1 2 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF064AA / 1 2 - / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0326 / 1 2 LL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B36258B / 1 2 - / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1166F / 1 2 - MO / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Appendicectomy, Barium enema, Haematemesis, Haematochezia, Intussusception, Surgery, Vomiting, Polymerase chain reaction, Adenovirus infection, Virus serology test

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit? (V2.0) No
Hospitalized? Yes, days: 4     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: (+) adenovirus PCR LABS: nasopharyngeal c/s +adenovirus. Rotavirus antigen neg. Abdominal x-ray revealed possible IS. US of abdomen revealed +IS. Barium enema attempt to reduce IS was unsuccessful.
CDC 'Split Type':

Write-up:4/14/07 - Presented with "coffee ground emesis" and bloody stools. Mom took him to ER, dx''d with adenovirus and intussusception. Unable to reduce with barium enema reduced with surgery. S/P Appendectomy. 6/1/07 Received vax record from PCP which indicates RO Lot # is as reported & was 2nd dose. VAERS database updated w/same. 6/5/07 Received hospital medical records which reveal patient experienced diarrhea x 7 days, bloody mucous x 1 day & abdominal pain. Also w/rhinorrhea, cough & sneeze. Admitted 4/14-4/17/07 for bacterial gastroenteritis. On initial hospital day had coffee ground emesis. Taken to OR for laproscopic reduction of IS & appendectomy. Stable post op FINAL DX: Ileocolic intussusception, surgically reduced; adenovirus.


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