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This is VAERS ID 291810

Case Details

VAERS ID: 291810 (history)  
Form: Version 1.0  
Age: 0.4  
Gender: Male  
Location: California  
Vaccinated:2007-09-04
Onset:2007-09-12
   Days after vaccination:8
Submitted: 2007-10-01
   Days after onset:19
Entered: 2007-10-02
   Days after submission:1
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124AA / 2 LL / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1273F / 2 RL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B9728313 / 2 RL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0972U / 2 MO / PO

Administered by: Public       Purchased by: Other
Symptoms: Intussusception
SMQs:, Gastrointestinal obstruction (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: 10/22/07-records received-well baby visits with c/o stuffy nose and cough.
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown 10/15/07-records received-BE positive for intussusception without complete reduction. TX successful reduction by air enema.
CDC Split Type: WAES0709USA03910

Write-up: Information has been received from a physician concerning a 5 month old male who on 04-SEP-2007 was vaccinated with a dose of Rotateq (no lot number provided). There was no concomitant medication. On 12-SEP-2007 the patient experienced intussusception. On that same day, the patient was examined by a physician and taken to the ER. At the time of this report the outcome was unknown. Additional information has been requested. 10/15/07-records received from facility-for DOS 09/12/07-patient with 36 hour history of abdominal pain, vomiting and passage of currant jelly stool times 1 today, BE positive for intussusception without complete reduction. TX successful reduction by air enema. 10/22/07-office notes received, lot#u055 included. well baby visits with c/o stuffy nose and cough.


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