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This is VAERS ID 284500

Case Details

VAERS ID: 284500 (history)  
Form: Version 1.0  
Age: 22.0  
Gender: Female  
Location: New Jersey  
   Days after vaccination:0
Submitted: 2007-06-14
   Days after onset:20
Entered: 2007-06-18
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Private       Purchased by: Private
Symptoms: Fall, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: TRIPHASIL
Current Illness: Penicillin allergy
Preexisting Conditions:
Diagnostic Lab Data: None
CDC Split Type: WAES0705USA05263

Write-up: This is in follow-up to report(s) previously submitted on 6/14/2007. Initial and follow up information has been received from a Licensed Practical Nurse (LPN) concerning a 22 year old female mathematician with a penicillin allergy and no pertinent medical history who was vaccinated with Gardasil on 25-MAY-2007, IM in to left arm with a first dose of GARDASIL lot #657736/0389U. Concomitant therapy included TRIPHASIL. In follow up it was reported that the patient received injection and remained seated for several minutes after injection. On 25-MAY-2007, at 02:00 PM she walked to front desk area to pay co-pay, while standing patient fell over towards left on nurse. The nurse grabbed patient and lowered to ground. The patient fainted five to minutes after receiving her first dose of Gardasil on 25-May-2007. Patient fainted and the nurse used ammonium acetate to revive patient. The patient revived and fully recovered within 15 minutes. No other information was reported. Additional information has been requested. Additional information is not expected.

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