This is VAERS ID 281104

(NOTE: This result is from the 9/14/2018 version of the VAERS database)

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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