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This is VAERS ID 289959

Case Details

VAERS ID: 289959 (history)  
Form: Version 1.0  
Age: 0.2  
Gender: Female  
Location: Washington  
Vaccinated:2007-08-24
Onset:2007-08-29
   Days after vaccination:5
Submitted: 2007-09-06
   Days after onset:8
Entered: 2007-09-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B129AA / 1 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF164AA / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B47300F / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0551U / 1 MO / PO

Administered by: Private       Purchased by: Public
Symptoms: Abdominal X-ray, Enema administration, Faeces discoloured, Intussusception, Irritability, Lethargy, Oral intake reduced, Vomiting
SMQs:, Acute pancreatitis (broad), Gastrointestinal obstruction (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hostility/aggression (broad), Noninfectious diarrhoea (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? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Pulmonary flow murmur; stenosis nasolacrimal duct
Allergies:
Diagnostic Lab Data: Gastro graffin BE LABS: UGI was WNL. Contrast enema (+) for IS & successfully reduced after 3rd attempt.
CDC Split Type:

Write-up: Symptoms started 8-29-07 with vomiting, decreased oral intake, lethargy, fussiness, intermittent green stools. Intussusception seen on gastrograffin BE and successful reduced. 9/11/07 Received hospital medical records which reveal patient experienced progressively bilious emesis blood tinged stools, decreased oral intake for approx 5 days & then becoming profoundly lethargic on day of admit 8/31-9/1/07. Kept overnight for observation s/p enema reduction of IS. Did well & d/c to home. FINAL DX: Intussusception, enema reduced. 9/11/07 T/C to pcp to request vax record to include lot #s. Unable to print. Verbally confirmed on phone that vax dose & lot #s correct as reported on VAERS form.


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