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This is VAERS ID 289041

Case Details

VAERS ID: 289041 (history)  
Form: Version 1.0  
Age: 0.3  
Gender: Male  
Location: Michigan  
Vaccinated:2007-06-14
Onset:2007-08-04
   Days after vaccination:51
Submitted: 2007-08-20
   Days after onset:16
Entered: 2007-08-27
   Days after submission:7
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114CA / 2 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1126F / 2 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08692H / 2 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0236U / 2 MO / PO

Administered by: Private       Purchased by: Private
Symptoms: Abdominal pain, Barium enema, Enema administration, Haematochezia, Intussusception, Mucous stools
SMQs:, Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Retroperitoneal fibrosis (broad), Gastrointestinal obstruction (narrow), Gastrointestinal haemorrhage (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Ischaemic colitis (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, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Confirmed by barium enema, Reduced by air enema LABS: Barium enema revealed IS in transverse colon. Air enema reduced. US of abdomen (+) IS recurrence, ileocolic IS & mesenteric adenitis. Blood work WNL.
CDC Split Type:

Write-up: Intussusception - 1 day intermittent symptoms with colicky abdominal pain, blood tinged mucous stool --$g reduced by air enema. 8/28/07 Received pcp medical records which included Hospital D/C summary & H&P. PCP records included vax records but no lot #s. T/C to pcp office, stated info on VAERS report correct & will not provide further info on lot #s. Office visit of 6/14 indicates patient was healthy on day of vax. F/U note of 8/07 indicates patient doing well post op. D/C Summary indicates paitent experienced mucousy emesis, decreased appetite, abdominal pain, fussy, listless & refusal to lie prone x 1 day & bloody mucously stool on day of admit. Admitted 8/4-8/5/07 for observation s/p IS reduction. Overnight, IS recurred as evidenced by (+) US. Then spontaneously resolved. FINAL DX: Intussusception, enema reduced. 9/17/07 Received lab & x-ray reports from hospital.


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