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This is VAERS ID 289405

Case Details

VAERS ID: 289405 (history)  
Form: Version 1.0  
Age: 0.5  
Gender: Male  
Location: Kansas  
Vaccinated:2007-08-03
Onset:2007-08-18
   Days after vaccination:15
Submitted: 2007-08-30
   Days after onset:12
Entered: 2007-08-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC27B124AA / 3 RA / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B47492K / 2 LL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0553U / 3 MO / PO

Administered by: Unknown       Purchased by: Unknown
Symptoms: Abdominal pain upper, Barium double contrast, Enema administration, Haematochezia, Intussusception, Pain, Vomiting, X-ray
SMQs:, Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), 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, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Other typical 6 month shots
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: x-ray, air enima LABS: US revealed IS. Air enema reduced IS.
CDC Split Type:

Write-up: Intusseption, bloody stool, vomitting of bile, stomach cramps, pain 8/31/07 Received vax record from pcp. VAERS database updated w/same./ss 9/28/07 Vax record faxed to CDC. 10/5/07 T/C to hospital to check status of request. States records faxed directly to CDC on 10/2/07. 10/5/07 Received hospital medical records which reveal patient experienced pallor, decreased bowel sounds, bilious vomiting, blood in stool & abdominal pain. Admitted 8/18-8/19/2007 for observation. Surgery consult done. reduction. Progressed well & d/c to home. FINAL DX: Intussusception.


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