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This is VAERS ID 279695

(NOTE: This result is from the 9/14/2017 version of the VAERS database)

Case Details

VAERS ID: 279695 (history)  
Form: Version 1.0  
Age: 0.3  
Gender: Male  
Location: New York  
Vaccinated:2007-05-04
Onset:2007-05-15
   Days after vaccination:11
Submitted: 2007-05-16
   Days after onset:1
Entered: 2007-05-25
   Days after submission:9
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS AC14B040CA / 2 - / IM
HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC. 1243F / 2 - / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08670D / 2 - / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 00224 / 2 MO / PO

Administered by: Private       Purchased by: Private
Symptoms: Abdominal X-ray, Carbon dioxide abnormal, Intussusception, Lethargy, Vomiting, X-ray abnormal
SMQs:, Acute pancreatitis (broad), Gastrointestinal obstruction (narrow), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: CO2 = 14 Abd film - air filled loops of distended small bowel. LABS: CBC & BMP WNL. Abdominal x-ray revealed IS. Air enema successcully reduced IS.
CDC Split Type:

Write-up: Intussusception with vomiting, lethargy. 6/5/07 Received vax records from PCP which confirms lot & dose # on report. Vax record faxed to CDC. 10/16/07 Received hospital medical records which reveal patient experienced irritability, decreased oral intake, tender abdomen, listlessness, vomiting & nonbloody diarrhea x 1 day. Had sick contact with viral enteritis. Saw pcp who palpated mass in RUQ & sent to ER. Admitted 5/15-5/16/2007 for overnight observation s/p reduction of IS. Progressed well & d/c to home. FINAL DX: ileocecal intussusception, enema reduced. Records faxed to CDC.


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