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This is VAERS ID 281104

Case Details

VAERS ID: 281104 (history)  
Form: Version 1.0  
Age: 0.3  
Gender: Male  
Location: Arizona  
Vaccinated:2007-05-02
Onset:2007-06-03
   Days after vaccination:32
Submitted: 2007-06-07
   Days after onset:4
Entered: 2007-06-11
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2553AA / 2 UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. UE924AA / 2 UN / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0018 / 2 UN / SC
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B47442A / 2 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1112F / 2 MO / PO

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

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, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: Intussusception. LABS: No lab reports were included w/records. Following was noted in D/C summary: US of abd showed IS. Air contrast unable to reduce. WBC 14.7. Chemistry WNL. Cultures neg. Echocardiogram revealed moderate membranous VSD & large amount of tissue transformation.
CDC Split Type:

Write-up: Intussusception. 6/12/07 Received vax record which confirms RO lot & dose # as correct. 7/31/07 Received hospital medical records which reveal patient experienced emesis & bloody stools. Admitted 6/3-6/7/07. Surgical consult & taken to OR for reduction of IS & right hemicolectomy w/ileocolostomy. Cardio consult done for heart murmur. Recovery uneventful. Surg & cardio f/u on d/c. FINAL DX: Intussusception, s/p right hemicolectomy & ileocolostomy; VSD.


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