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This is VAERS ID 286493

History of Changes from the VAERS Wayback Machine

First Appeared on 12/31/2007

VAERS ID: 286493
VAERS Form:
Age:0.2
Gender:Male
Location:Mississippi
Vaccinated:2007-04-03
Onset:2007-06-01
Submitted:2007-08-01
Entered:2007-08-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B090AA / 0 LL / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0658F / 0 RL / -
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B08681D / 0 RL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1232F / 0 - / PO

Administered by: Other      Purchased by: Unknown
Symptoms: Abdominal pain, Barium enema, Computerised tomogram normal, Explorative laparotomy, Abdominal X-ray

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: Information has been received from a physician concerning an approximately 5 month old male who on 05-APR-2007 was vaccinated orally with a 2 ml dose of Rotateq (lot# 656192/0022U). Subsequently, the patient experienced intussusception, was hospitalized a"nd released after surgery. On an unspecified ate, the patient recovered. No product quality complaint was involved. A lot check was requested. Intussusception was considered to be immediately life-threatening and an other important medical event. Addition


Changed on 12/8/2009

VAERS ID: 286493 Before After
VAERS Form:
Age:0.2
Gender:Male
Location:Mississippi
Vaccinated:2007-04-03
Onset:2007-06-01
Submitted:2007-08-01
Entered:2007-08-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B090AA / 0 LL / -
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B090AA / 0 LL / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0658F / 0 RL / -
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B08681D / 0 RL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1232F / 0 - / PO

Administered by: Other      Purchased by: Unknown Other
Symptoms: Abdominal pain, Barium enema, Computerised tomogram normal, Haematemesis, Haematochezia, Intussusception, Lethargy, Rash, Sneezing, Surgery, Urinary system X-ray, Vomiting, X-ray with contrast upper gastrointestinal tract, Explorative laparotomy, Polyp, Abdominal X-ray

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Unknown Birth HX: preterm 37.5 wks. jaundice.
Allergies:
Diagnostic Lab Data: Unknown LABS: CT of head in ER was WNL. KUB in ER revealed obstruction. Abdominal x-ray. UGI showed poor peristalsis. Water soluble BE revealed ileocolic IS, only partially reduced.
CDC 'Split Type': (blank) WAES0707USA03737

Write-up: Information has been received from a physician concerning an approximately 5 month old male who on 05-APR-2007 was vaccinated orally with a 2 ml dose of Rotateq (lot# 656192/0022U). Subsequently, the patient experienced intussusception, was hospitalized a"nd and released after surgery. On an unspecified ate, the patient recovered. No product quality complaint was involved. A lot check was requested. Intussusception was considered to be immediately life-threatening and an other important medical event. Addition Additional information has been requested. 9/11/07 Reviewed pcp medical records & vax records which corrected vax lot #. VAERS database updated w/same. Records reveal patient experienced good health w/sneezing, pinpoint facial rash & colic. Hospitalized 6/1-6/6 for intestinal polyp surgery. Received 2nd dose RO on 6/21. 3rd dose held. 9/25/07 Reviewed hospital medical records which reveal patient experienced bilious emesis on day of admit 6/2-6/6/2007 followed by coffee grounds emesis & bloody stool. Seen at outside ER & transferred for higher level of care. Upon admit was lethargic, abdomen soft & nondistended & no mass palpable. To OR for exp laparotomy & reduction of ileocolonic IS. Did well post op & d/c to home when tolerating oral feeds & having stool. FINAL DX: Ileocolonic Intussusception, surgically reduced. 9/25/07 pcp medical records & vax record faxed to CDC.


Changed on 3/2/2010

VAERS ID: 286493 Before After
VAERS Form:
Age:0.2
Gender:Male
Location:Mississippi
Vaccinated:2007-04-03
Onset:2007-06-01
Submitted:2007-08-01
Entered:2007-08-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B090AA / 0 LL / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0658F / 0 RL / -
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC B08681D / 0 RL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1232F / 0 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal pain, Barium enema, Computerised tomogram normal, Haematemesis, Haematochezia, Intussusception, Lethargy, Rash, Sneezing, Surgery, Urinary system X-ray, Vomiting, X-ray with contrast upper gastrointestinal tract, Explorative laparotomy, Polyp, Abdominal X-ray

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Unknown Birth HX: preterm 37.5 wks. jaundice.
Allergies:
Diagnostic Lab Data: Unknown LABS: CT of head in ER was WNL. KUB in ER revealed obstruction. Abdominal x-ray. UGI showed poor peristalsis. Water soluble BE revealed ileocolic IS, only partially reduced.
CDC 'Split Type': WAES0707USA03737

Write-up: Information has been received from a physician concerning an approximately 5 month old male who on 05-APR-2007 was vaccinated orally with a 2 ml dose of Rotateq (lot# 656192/0022U). Subsequently, the patient experienced intussusception, was hospitalized and released after surgery. On an unspecified ate, the patient recovered. No product quality complaint was involved. A lot check was requested. Intussusception was considered to be immediately life-threatening and an other important medical event. Additional information has been requested. 9/11/07 Reviewed pcp medical records & vax records which corrected vax lot #. VAERS database updated w/same. Records reveal patient experienced good health w/sneezing, pinpoint facial rash & colic. Hospitalized 6/1-6/6 for intestinal polyp surgery. Received 2nd dose RO on 6/21. 3rd dose held. 9/25/07 Reviewed hospital medical records which reveal patient experienced bilious emesis on day of admit 6/2-6/6/2007 followed by coffee grounds emesis & bloody stool. Seen at outside ER & transferred for higher level of care. Upon admit was lethargic, abdomen soft & nondistended & no mass palpable. To OR for exp laparotomy & reduction of ileocolonic IS. Did well post op & d/c to home when tolerating oral feeds & having stool. FINAL DX: Ileocolonic Intussusception, surgically reduced. 9/25/07 pcp medical records & vax record faxed to CDC.


Changed on 4/7/2010

VAERS ID: 286493 Before After
VAERS Form:
Age:0.2
Gender:Male
Location:Mississippi
Vaccinated:2007-04-03
Onset:2007-06-01
Submitted:2007-08-01
Entered:2007-08-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B090AA / 0 LL / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0658F / 0 RL / -
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B08681D / 0 RL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1232F / 0 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal pain, Barium enema, Computerised tomogram normal, Haematemesis, Haematochezia, Intussusception, Lethargy, Rash, Sneezing, Surgery, Urinary system X-ray, Vomiting, X-ray with contrast upper gastrointestinal tract, Explorative laparotomy, Polyp, Abdominal X-ray

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Unknown Birth HX: preterm 37.5 wks. jaundice.
Allergies:
Diagnostic Lab Data: Unknown LABS: CT of head in ER was WNL. KUB in ER revealed obstruction. Abdominal x-ray. UGI showed poor peristalsis. Water soluble BE revealed ileocolic IS, only partially reduced.
CDC 'Split Type': WAES0707USA03737

Write-up: Information has been received from a physician concerning an approximately 5 month old male who on 05-APR-2007 was vaccinated orally with a 2 ml dose of Rotateq (lot# 656192/0022U). Subsequently, the patient experienced intussusception, was hospitalized and released after surgery. On an unspecified ate, the patient recovered. No product quality complaint was involved. A lot check was requested. Intussusception was considered to be immediately life-threatening and an other important medical event. Additional information has been requested. 9/11/07 Reviewed pcp medical records & vax records which corrected vax lot #. VAERS database updated w/same. Records reveal patient experienced good health w/sneezing, pinpoint facial rash & colic. Hospitalized 6/1-6/6 for intestinal polyp surgery. Received 2nd dose RO on 6/21. 3rd dose held. 9/25/07 Reviewed hospital medical records which reveal patient experienced bilious emesis on day of admit 6/2-6/6/2007 followed by coffee grounds emesis & bloody stool. Seen at outside ER & transferred for higher level of care. Upon admit was lethargic, abdomen soft & nondistended & no mass palpable. To OR for exp laparotomy & reduction of ileocolonic IS. Did well post op & d/c to home when tolerating oral feeds & having stool. FINAL DX: Ileocolonic Intussusception, surgically reduced. 9/25/07 pcp medical records & vax record faxed to CDC.


Changed on 8/31/2010

VAERS ID: 286493 Before After
VAERS Form:
Age:0.2
Gender:Male
Location:Mississippi
Vaccinated:2007-04-03
Onset:2007-06-01
Submitted:2007-08-01
Entered:2007-08-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B090AA / 0 LL / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0658F / 0 RL / -
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH B08681D / 0 RL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1232F / 0 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal pain, Barium enema, Computerised tomogram normal, Haematemesis, Haematochezia, Intussusception, Lethargy, Rash, Sneezing, Surgery, Urinary system X-ray, Vomiting, X-ray with contrast upper gastrointestinal tract, Explorative laparotomy, Polyp, Abdominal X-ray

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Unknown Birth HX: preterm 37.5 wks. jaundice.
Allergies:
Diagnostic Lab Data: Unknown LABS: CT of head in ER was WNL. KUB in ER revealed obstruction. Abdominal x-ray. UGI showed poor peristalsis. Water soluble BE revealed ileocolic IS, only partially reduced.
CDC 'Split Type': WAES0707USA03737

Write-up: Information has been received from a physician concerning an approximately 5 month old male who on 05-APR-2007 was vaccinated orally with a 2 ml dose of Rotateq (lot# 656192/0022U). Subsequently, the patient experienced intussusception, was hospitalized and released after surgery. On an unspecified ate, the patient recovered. No product quality complaint was involved. A lot check was requested. Intussusception was considered to be immediately life-threatening and an other important medical event. Additional information has been requested. 9/11/07 Reviewed pcp medical records & vax records which corrected vax lot #. VAERS database updated w/same. Records reveal patient experienced good health w/sneezing, pinpoint facial rash & colic. Hospitalized 6/1-6/6 for intestinal polyp surgery. Received 2nd dose RO on 6/21. 3rd dose held. 9/25/07 Reviewed hospital medical records which reveal patient experienced bilious emesis on day of admit 6/2-6/6/2007 followed by coffee grounds emesis & bloody stool. Seen at outside ER & transferred for higher level of care. Upon admit was lethargic, abdomen soft & nondistended & no mass palpable. To OR for exp laparotomy & reduction of ileocolonic IS. Did well post op & d/c to home when tolerating oral feeds & having stool. FINAL DX: Ileocolonic Intussusception, surgically reduced. 9/25/07 pcp medical records & vax record faxed to CDC.


Changed on 5/13/2013

VAERS ID: 286493 Before After
VAERS Form:
Age:0.2
Gender:Male
Location:Mississippi
Vaccinated:2007-04-03
Onset:2007-06-01
Submitted:2007-08-01
Entered:2007-08-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B090AA / 0 LL / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0658F / 0 RL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08681D / 0 RL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1232F / 0 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1232F / 0 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal pain, Barium enema, Computerised tomogram normal, Haematemesis, Haematochezia, Intussusception, Lethargy, Rash, Sneezing, Surgery, Urinary system X-ray, Vomiting, X-ray with contrast upper gastrointestinal tract, Explorative laparotomy, Polyp, Abdominal X-ray

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Unknown Birth HX: preterm 37.5 wks. jaundice.
Allergies:
Diagnostic Lab Data: Unknown LABS: CT of head in ER was WNL. KUB in ER revealed obstruction. Abdominal x-ray. UGI showed poor peristalsis. Water soluble BE revealed ileocolic IS, only partially reduced.
CDC 'Split Type': WAES0707USA03737

Write-up: Information has been received from a physician concerning an approximately 5 month old male who on 05-APR-2007 was vaccinated orally with a 2 ml dose of Rotateq (lot# 656192/0022U). Subsequently, the patient experienced intussusception, was hospitalized and released after surgery. On an unspecified ate, the patient recovered. No product quality complaint was involved. A lot check was requested. Intussusception was considered to be immediately life-threatening and an other important medical event. Additional information has been requested. 9/11/07 Reviewed pcp medical records & vax records which corrected vax lot #. VAERS database updated w/same. Records reveal patient experienced good health w/sneezing, pinpoint facial rash & colic. Hospitalized 6/1-6/6 for intestinal polyp surgery. Received 2nd dose RO on 6/21. 3rd dose held. 9/25/07 Reviewed hospital medical records which reveal patient experienced bilious emesis on day of admit 6/2-6/6/2007 followed by coffee grounds emesis & bloody stool. Seen at outside ER & transferred for higher level of care. Upon admit was lethargic, abdomen soft & nondistended & no mass palpable. To OR for exp laparotomy & reduction of ileocolonic IS. Did well post op & d/c to home when tolerating oral feeds & having stool. FINAL DX: Ileocolonic Intussusception, surgically reduced. 9/25/07 pcp medical records & vax record faxed to CDC.


Changed on 5/14/2017

VAERS ID: 286493 Before After
VAERS Form:
Age:0.2
Gender:Male
Location:Mississippi
Vaccinated:2007-04-03
Onset:2007-06-01
Submitted:2007-08-01
Entered:2007-08-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B090AA / 0 LL / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0658F / 0 RL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08681D / 0 RL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1232F / 0 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal pain, Barium enema, Computerised tomogram normal, Haematemesis, Haematochezia, Intussusception, Lethargy, Rash, Sneezing, Surgery, Urinary system X-ray, Vomiting, X-ray with contrast upper gastrointestinal tract, Explorative laparotomy, Polyp, Abdominal X-ray

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Unknown Birth HX: preterm 37.5 wks. jaundice.
Allergies:
Diagnostic Lab Data: Unknown LABS: CT of head in ER was WNL. KUB in ER revealed obstruction. Abdominal x-ray. UGI showed poor peristalsis. Water soluble BE revealed ileocolic IS, only partially reduced.
CDC 'Split Type': WAES0707USA03737

Write-up: Information has been received from a physician concerning an approximately 5 month old male who on 05-APR-2007 was vaccinated orally with a 2 ml dose of Rotateq (lot# 656192/0022U). Subsequently, the patient experienced intussusception, was hospitalized and released after surgery. On an unspecified ate, the patient recovered. No product quality complaint was involved. A lot check was requested. Intussusception was considered to be immediately life-threatening and an other important medical event. Additional information has been requested. 9/11/07 Reviewed pcp medical records & vax records which corrected vax lot #. VAERS database updated w/same. Records reveal patient experienced good health w/sneezing, pinpoint facial rash & colic. Hospitalized 6/1-6/6 for intestinal polyp surgery. Received 2nd dose RO on 6/21. 3rd dose held. 9/25/07 Reviewed hospital medical records which reveal patient experienced bilious emesis on day of admit 6/2-6/6/2007 followed by coffee grounds emesis & bloody stool. Seen at outside ER & transferred for higher level of care. Upon admit was lethargic, abdomen soft & nondistended & no mass palpable. To OR for exp laparotomy & reduction of ileocolonic IS. Did well post op & d/c to home when tolerating oral feeds & having stool. FINAL DX: Ileocolonic Intussusception, surgically reduced. 9/25/07 pcp medical records & vax record faxed to CDC.


Changed on 9/14/2017

VAERS ID: 286493 Before After
VAERS Form:(blank) 1
Age:0.2
Gender:Male
Location:Mississippi
Vaccinated:2007-04-03
Onset:2007-06-01
Submitted:2007-08-01
Entered:2007-08-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B090AA / 0 1 LL / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0658F / 0 1 RL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08681D / 0 1 RL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1232F / 0 1 - MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Intussusception, Surgery

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Unknown Birth HX: preterm 37.5 wks. jaundice.
Allergies:
Diagnostic Lab Data: Unknown LABS: CT of head in ER was WNL. KUB in ER revealed obstruction. Abdominal x-ray. UGI showed poor peristalsis. Water soluble BE revealed ileocolic IS, only partially reduced.
CDC 'Split Type': WAES0707USA03737

Write-up: Information has been received from a physician concerning an approximately 5 month old male who on 05-APR-2007 was vaccinated orally with a 2 ml dose of Rotateq (lot# 656192/0022U). Subsequently, the patient experienced intussusception, was hospitalized and released after surgery. On an unspecified ate, the patient recovered. No product quality complaint was involved. A lot check was requested. Intussusception was considered to be immediately life-threatening and an other important medical event. Additional information has been requested. 9/11/07 Reviewed pcp medical records & vax records which corrected vax lot #. VAERS database updated w/same. Records reveal patient experienced good health w/sneezing, pinpoint facial rash & colic. Hospitalized 6/1-6/6 for intestinal polyp surgery. Received 2nd dose RO on 6/21. 3rd dose held. 9/25/07 Reviewed hospital medical records which reveal patient experienced bilious emesis on day of admit 6/2-6/6/2007 followed by coffee grounds emesis & bloody stool. Seen at outside ER & transferred for higher level of care. Upon admit was lethargic, abdomen soft & nondistended & no mass palpable. To OR for exp laparotomy & reduction of ileocolonic IS. Did well post op & d/c to home when tolerating oral feeds & having stool. FINAL DX: Ileocolonic Intussusception, surgically reduced. 9/25/07 pcp medical records & vax record faxed to CDC.


Changed on 2/14/2018

VAERS ID: 286493 Before After
VAERS Form:1
Age:0.2
Gender:Male
Location:Mississippi
Vaccinated:2007-04-03
Onset:2007-06-01
Submitted:2007-08-01
Entered:2007-08-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B090AA / 1 LL / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0658F / 1 RL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08681D / 1 RL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1232F / 1 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Intussusception, Surgery

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Unknown Birth HX: preterm 37.5 wks. jaundice.
Allergies:
Diagnostic Lab Data: Unknown LABS: CT of head in ER was WNL. KUB in ER revealed obstruction. Abdominal x-ray. UGI showed poor peristalsis. Water soluble BE revealed ileocolic IS, only partially reduced.
CDC 'Split Type': WAES0707USA03737

Write-up: Information has been received from a physician concerning an approximately 5 month old male who on 05-APR-2007 was vaccinated orally with a 2 ml dose of Rotateq (lot# 656192/0022U). Subsequently, the patient experienced intussusception, was hospitalized and released after surgery. On an unspecified ate, the patient recovered. No product quality complaint was involved. A lot check was requested. Intussusception was considered to be immediately life-threatening and an other important medical event. Additional information has been requested. 9/11/07 Reviewed pcp medical records & vax records which corrected vax lot #. VAERS database updated w/same. Records reveal patient experienced good health w/sneezing, pinpoint facial rash & colic. Hospitalized 6/1-6/6 for intestinal polyp surgery. Received 2nd dose RO on 6/21. 3rd dose held. 9/25/07 Reviewed hospital medical records which reveal patient experienced bilious emesis on day of admit 6/2-6/6/2007 followed by coffee grounds emesis & bloody stool. Seen at outside ER & transferred for higher level of care. Upon admit was lethargic, abdomen soft & nondistended & no mass palpable. To OR for exp laparotomy & reduction of ileocolonic IS. Did well post op & d/c to home when tolerating oral feeds & having stool. FINAL DX: Ileocolonic Intussusception, surgically reduced. 9/25/07 pcp medical records & vax record faxed to CDC.


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