| VAERS ID: |
281725 (history) |
| Form: |
Version .0 |
| Age: |
0.3 |
| Gender: |
Male |
| Location: |
California |
| Vaccinated: | 2007-04-12 |
| Onset: | 2007-05-30 |
| Days after vaccination: | 48 |
| Submitted: |
2007-06-06 |
| Days after onset: | 7 |
| Entered: |
2007-06-14 |
| Days after submission: | 8 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR |
C2510BA / 1 |
RL / - |
| HIBV: HIB (ACTHIB) / SANOFI PASTEUR |
UFO91AA / 1 |
LL / - |
| IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR |
20457 / 1 |
LL / - |
| PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC |
B08689D / 1 |
RL / - |
| ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. |
1237F / 1 |
- / PO |
Administered by: Private Purchased by: Unknown
Symptoms: Abdominal pain,
Barium enema,
Blood test normal,
Crying,
Decreased appetite,
Intussusception,
Irritability,
Screaming,
Somnolence,
Urinary system X-ray,
X-ray
SMQs:, Acute pancreatitis (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Dementia (broad), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hostility/aggression (broad), Depression (excl suicide and self injury) (broad)
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, 1 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: Barium enema, X rays LABS: KUB in ER suggested IS. Barium enema done which was neg. Blood work was all WNL
CDC Split Type:
Write-up: Waxing, weaning fussiness Dx : intussusception. 6/21/07 Received vax rec which confirms RO lot & dose # & also includes multi additional vax received same date. VAERS database updated w/same. 6/26/07 Received hospital med recs which reveal that on 5/30/07 patient experienced screaming & fussiness then excess sleepiness. When awake, inconsolable, refusal to eat & drawing legs up. Taken to PCP office & sent to ER. Felt to have resolved IS spontaneously. Held overnight for observation. Tolerated oral intake well & was d/c to home 5/31/07. FINAL DX: none provided, no D/C summary done. |
