| VAERS ID: |
278006 (history) |
| Form: |
Version .0 |
| Age: |
0.5 |
| Gender: |
Female |
| Location: |
California |
| Vaccinated: | 2006-12-29 |
| Onset: | 2007-04-26 |
| Days after vaccination: | 118 |
| Submitted: |
2007-05-02 |
| Days after onset: | 6 |
| Entered: |
2007-05-07 |
| Days after submission: | 5 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR |
U1965AB / - |
LL / IM |
| HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. |
0032F / 2 |
RL / IM |
| HIBV: HIB (ACTHIB) / SANOFI PASTEUR |
UF018AD / 2 |
LL / IM |
| IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR |
Y10312 / 2 |
RL / SC |
| PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC |
B08646C / 2 |
RL / IM |
| ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. |
1110F / 2 |
- / PO |
Administered by: Private Purchased by: Private
Symptoms: Abdominal pain,
Barium enema,
Full blood count normal,
Haematochezia,
Inappropriate schedule of drug administration,
Intussusception,
Laboratory test normal,
Lethargy,
Ultrasound abdomen abnormal,
Vomiting
SMQs:, Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Retroperitoneal fibrosis (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 (narrow), Ischaemic colitis (broad)
Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: Hospitalized Abdominal US abnormal, barium enema cbc & chemistry both WNL.
CDC Split Type:
Write-up: Intussusception 5/15/07 Received vax records from reporter. Lot numbers corrected in VAERS database. RO lot number & dose confirmed by vax records. 5/25/07 Received medical records from hospital which reveal patient experienced emesis, bloody stools, abdominal pain & lethargy. IS at right hepatic flexure diagnosed by abd US & reduced by barium enema. Admitted 4/27 & d/c later same day after observation s/p IS reduction. Consult by peds surgery done. FINAL DX: Intussusception. |
