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This is VAERS ID 281104

(NOTE: This result is from the 12/8/2009 version of the VAERS database)

Case Details

VAERS ID: 281104 (history)  
Form: Version .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 / 1 UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. UE924AA / 1 UN / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0018 / 1 UN / SC
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B47442A / 1 UN / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1112F / 1 - / PO

Administered by: Private       Purchased by: Private
Symptoms: Cardiac murmur, Colectomy, Colostomy, Culture negative, Echocardiogram abnormal, Enema administration, Haematochezia, Intussusception, Laboratory test normal, Surgery, Ultrasound abdomen abnormal, Ventricular septal defect, Vomiting, White blood cell count normal
SMQs:, Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Retroperitoneal fibrosis (broad), Congenital, familial and genetic disorders (narrow), Malignancy related therapeutic and diagnostic procedures (narrow), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Gastrointestinal haemorrhage (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Ischaemic colitis (broad), Cardiomyopathy (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, 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
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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