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This is VAERS ID 280057

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

Case Details

VAERS ID: 280057 (history)  
Form: Version 1.0  
Age: 0.5  
Gender: Male  
Location: California  
Vaccinated:2007-03-13
Onset:2007-05-16
   Days after vaccination:64
Submitted: 2007-05-30
   Days after onset:14
Entered: 2007-05-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (NO BRAND NAME) / UNKNOWN MANUFACTURER C2407AA / 3 LL / IM
HIBV: HIB (NO BRAND NAME) / UNKNOWN MANUFACTURER VF019AA / 3 RL / IM
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / UNKNOWN MANUFACTURER Z0324 / 3 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 836258A / 3 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0980F / 3 MO / PO

Administered by: Unknown       Purchased by: Unknown
Symptoms: Intussusception
SMQs:, Gastrointestinal obstruction (narrow)

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, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: No
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Labs and Diagnostics: KUB showed evidence of bowel obstruction. Barium enema attempted however pt. desaturated and became tachycardic.
CDC Split Type:

Write-up: Patient had 3 doses of Oral Rotavirus vaccine, at 2 mo, 4 mo and 6 mo of age. Patient was diagnosed with intussusception at 8mo of age. 5/16/07. 06/12/2007 Hospital record received for admission 5/16-18/2007 Intussusception. Infant presented to ED with persistant vomiting, black stool, decreased po fluids, and not seeming quite himself. He may have fallen out of bed the morning of admission. PE: WNL except for tenderness of the abdomen with decreased BS. Hydrostatic reduction done under general anesthesia. D/C DX: Intussusception.


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