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This is VAERS ID 292129

History of Changes from the VAERS Wayback Machine

First Appeared on 12/31/2007

VAERS ID: 292129
VAERS Form:
Age:0.5
Gender:Male
Location:Missouri
Vaccinated:2007-05-23
Onset:2007-09-04
Submitted:2007-10-03
Entered:2007-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B113AA / 3 LL / -
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC BO8679F / 3 RL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 00030U / 3 - / PO

Administered by: Other      Purchased by: Unknown
Symptoms: Abdominal distension, Barium enema, Computerised tomogram abnormal, Dehydration, Colectomy

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 14     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 a 10 month old patient (gender not reported) who on an unspecified date was vaccinated with the completed 3 dose series of Rotateq. Subsequently the patient experienced intussusception and was hosp"italized. The intussusception was corrected surgically. On an unspecified date, the patient recovered from intussusception. Intussusception was considered to be immediately life-threatening. Additional information has been requested.


Changed on 12/8/2009

VAERS ID: 292129 Before After
VAERS Form:
Age:0.5
Gender:Male
Location:Missouri
Vaccinated:2007-05-23
Onset:2007-09-04
Submitted:2007-10-03
Entered:2007-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B113AA / 3 LL / -
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B113AA / 3 LL / -
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC BO8679F / 3 RL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 00030U / 3 - / PO

Administered by: Other      Purchased by: Unknown Other
Symptoms: Abdominal distension, Barium enema, Computerised tomogram abnormal, Dehydration, Gastroenteritis, Haematochezia, Ileus, Inappropriate schedule of drug administration, Intestinal obstruction, Intussusception, Malaise, Pyrexia, Surgery, Vomiting, Explorative laparotomy, Intestinal anastomosis, Colectomy

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 14     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown LABS: BE revealed IS. CT of abdomen revealed bowel obstruction or severe ileus.
CDC 'Split Type': (blank) WAES0710USA00021

Write-up: Information has been received from a physician concerning a 10 month old patient (gender not reported) who on an unspecified date was vaccinated with the completed 3 dose series of Rotateq. Subsequently the patient experienced intussusception and was hosp"italized. hospitalized. The intussusception was corrected surgically. On an unspecified date, the patient recovered from intussusception. Intussusception was considered to be immediately life-threatening. Additional information has been requested. 10/8/07 Patient demographics provided by CDC. 10/26/07 Received vax record & VAERS database updated w/same. Also received tag 2 report from pcp which included AE onset. Record faxed to CDC. 11/27/07 Reviewed hospital medical records which reveal patient experienced blood in stools, fever & vomiting x 2 days. Seen by pcp who dx w/gastroenteritis & sent home. Vomiting continued & taken to ER. Admitted 9/5-9/18/2007. He appeared dehydrated & ill. BE done revealed colocolic IS but not able to reduce. Taken to OR where exp laparotomy with right extended hemicolectomy w/primary anastomosis & re-exploration laparoscopically with open reduction of IS was done. Did well initially post operatively but on day 3-4 became distended & vomited. Continued for several days & unable to tolerate oral feeds. Taken back to OR where second IS was found & easily reduced. Progressed well after 2nd surgery & d/c to home. FINAL DX: Intussusception, recurrent, surgically reduced x 2 with hemicolectomy. Records faxed to CDC.


Changed on 3/2/2010

VAERS ID: 292129 Before After
VAERS Form:
Age:0.5
Gender:Male
Location:Missouri
Vaccinated:2007-05-23
Onset:2007-09-04
Submitted:2007-10-03
Entered:2007-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B113AA / 3 LL / -
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC BO8679F / 3 RL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 00030U / 3 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal distension, Barium enema, Computerised tomogram abnormal, Dehydration, Gastroenteritis, Haematochezia, Ileus, Inappropriate schedule of drug administration, Intestinal obstruction, Intussusception, Malaise, Pyrexia, Surgery, Vomiting, Explorative laparotomy, Intestinal anastomosis, Colectomy

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 14     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown LABS: BE revealed IS. CT of abdomen revealed bowel obstruction or severe ileus.
CDC 'Split Type': WAES0710USA00021

Write-up: Information has been received from a physician concerning a 10 month old patient (gender not reported) who on an unspecified date was vaccinated with the completed 3 dose series of Rotateq. Subsequently the patient experienced intussusception and was hospitalized. The intussusception was corrected surgically. On an unspecified date, the patient recovered from intussusception. Intussusception was considered to be immediately life-threatening. Additional information has been requested. 10/8/07 Patient demographics provided by CDC. 10/26/07 Received vax record & VAERS database updated w/same. Also received tag 2 report from pcp which included AE onset. Record faxed to CDC. 11/27/07 Reviewed hospital medical records which reveal patient experienced blood in stools, fever & vomiting x 2 days. Seen by pcp who dx w/gastroenteritis & sent home. Vomiting continued & taken to ER. Admitted 9/5-9/18/2007. He appeared dehydrated & ill. BE done revealed colocolic IS but not able to reduce. Taken to OR where exp laparotomy with right extended hemicolectomy w/primary anastomosis & re-exploration laparoscopically with open reduction of IS was done. Did well initially post operatively but on day 3-4 became distended & vomited. Continued for several days & unable to tolerate oral feeds. Taken back to OR where second IS was found & easily reduced. Progressed well after 2nd surgery & d/c to home. FINAL DX: Intussusception, recurrent, surgically reduced x 2 with hemicolectomy. Records faxed to CDC.


Changed on 4/7/2010

VAERS ID: 292129 Before After
VAERS Form:
Age:0.5
Gender:Male
Location:Missouri
Vaccinated:2007-05-23
Onset:2007-09-04
Submitted:2007-10-03
Entered:2007-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B113AA / 3 LL / -
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC BO8679F / 3 RL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 00030U / 3 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal distension, Barium enema, Computerised tomogram abnormal, Dehydration, Gastroenteritis, Haematochezia, Ileus, Inappropriate schedule of drug administration, Intestinal obstruction, Intussusception, Malaise, Pyrexia, Surgery, Vomiting, Explorative laparotomy, Intestinal anastomosis, Colectomy

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 14     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown LABS: BE revealed IS. CT of abdomen revealed bowel obstruction or severe ileus.
CDC 'Split Type': WAES0710USA00021

Write-up: Information has been received from a physician concerning a 10 month old patient (gender not reported) who on an unspecified date was vaccinated with the completed 3 dose series of Rotateq. Subsequently the patient experienced intussusception and was hospitalized. The intussusception was corrected surgically. On an unspecified date, the patient recovered from intussusception. Intussusception was considered to be immediately life-threatening. Additional information has been requested. 10/8/07 Patient demographics provided by CDC. 10/26/07 Received vax record & VAERS database updated w/same. Also received tag 2 report from pcp which included AE onset. Record faxed to CDC. 11/27/07 Reviewed hospital medical records which reveal patient experienced blood in stools, fever & vomiting x 2 days. Seen by pcp who dx w/gastroenteritis & sent home. Vomiting continued & taken to ER. Admitted 9/5-9/18/2007. He appeared dehydrated & ill. BE done revealed colocolic IS but not able to reduce. Taken to OR where exp laparotomy with right extended hemicolectomy w/primary anastomosis & re-exploration laparoscopically with open reduction of IS was done. Did well initially post operatively but on day 3-4 became distended & vomited. Continued for several days & unable to tolerate oral feeds. Taken back to OR where second IS was found & easily reduced. Progressed well after 2nd surgery & d/c to home. FINAL DX: Intussusception, recurrent, surgically reduced x 2 with hemicolectomy. Records faxed to CDC.


Changed on 8/31/2010

VAERS ID: 292129 Before After
VAERS Form:
Age:0.5
Gender:Male
Location:Missouri
Vaccinated:2007-05-23
Onset:2007-09-04
Submitted:2007-10-03
Entered:2007-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B113AA / 3 LL / -
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH BO8679F / 3 RL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 00030U / 3 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal distension, Barium enema, Computerised tomogram abnormal, Dehydration, Gastroenteritis, Haematochezia, Ileus, Inappropriate schedule of drug administration, Intestinal obstruction, Intussusception, Malaise, Pyrexia, Surgery, Vomiting, Explorative laparotomy, Intestinal anastomosis, Colectomy

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 14     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown LABS: BE revealed IS. CT of abdomen revealed bowel obstruction or severe ileus.
CDC 'Split Type': WAES0710USA00021

Write-up: Information has been received from a physician concerning a 10 month old patient (gender not reported) who on an unspecified date was vaccinated with the completed 3 dose series of Rotateq. Subsequently the patient experienced intussusception and was hospitalized. The intussusception was corrected surgically. On an unspecified date, the patient recovered from intussusception. Intussusception was considered to be immediately life-threatening. Additional information has been requested. 10/8/07 Patient demographics provided by CDC. 10/26/07 Received vax record & VAERS database updated w/same. Also received tag 2 report from pcp which included AE onset. Record faxed to CDC. 11/27/07 Reviewed hospital medical records which reveal patient experienced blood in stools, fever & vomiting x 2 days. Seen by pcp who dx w/gastroenteritis & sent home. Vomiting continued & taken to ER. Admitted 9/5-9/18/2007. He appeared dehydrated & ill. BE done revealed colocolic IS but not able to reduce. Taken to OR where exp laparotomy with right extended hemicolectomy w/primary anastomosis & re-exploration laparoscopically with open reduction of IS was done. Did well initially post operatively but on day 3-4 became distended & vomited. Continued for several days & unable to tolerate oral feeds. Taken back to OR where second IS was found & easily reduced. Progressed well after 2nd surgery & d/c to home. FINAL DX: Intussusception, recurrent, surgically reduced x 2 with hemicolectomy. Records faxed to CDC.


Changed on 5/13/2013

VAERS ID: 292129 Before After
VAERS Form:
Age:0.5
Gender:Male
Location:Missouri
Vaccinated:2007-05-23
Onset:2007-09-04
Submitted:2007-10-03
Entered:2007-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B113AA / 3 LL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH BO8679F / 3 RL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 00030U / 3 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 00030U / 3 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal distension, Barium enema, Computerised tomogram abnormal, Dehydration, Gastroenteritis, Haematochezia, Ileus, Inappropriate schedule of drug administration, Intestinal obstruction, Intussusception, Malaise, Pyrexia, Surgery, Vomiting, Explorative laparotomy, Intestinal anastomosis, Colectomy

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 14     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown LABS: BE revealed IS. CT of abdomen revealed bowel obstruction or severe ileus.
CDC 'Split Type': WAES0710USA00021

Write-up: Information has been received from a physician concerning a 10 month old patient (gender not reported) who on an unspecified date was vaccinated with the completed 3 dose series of Rotateq. Subsequently the patient experienced intussusception and was hospitalized. The intussusception was corrected surgically. On an unspecified date, the patient recovered from intussusception. Intussusception was considered to be immediately life-threatening. Additional information has been requested. 10/8/07 Patient demographics provided by CDC. 10/26/07 Received vax record & VAERS database updated w/same. Also received tag 2 report from pcp which included AE onset. Record faxed to CDC. 11/27/07 Reviewed hospital medical records which reveal patient experienced blood in stools, fever & vomiting x 2 days. Seen by pcp who dx w/gastroenteritis & sent home. Vomiting continued & taken to ER. Admitted 9/5-9/18/2007. He appeared dehydrated & ill. BE done revealed colocolic IS but not able to reduce. Taken to OR where exp laparotomy with right extended hemicolectomy w/primary anastomosis & re-exploration laparoscopically with open reduction of IS was done. Did well initially post operatively but on day 3-4 became distended & vomited. Continued for several days & unable to tolerate oral feeds. Taken back to OR where second IS was found & easily reduced. Progressed well after 2nd surgery & d/c to home. FINAL DX: Intussusception, recurrent, surgically reduced x 2 with hemicolectomy. Records faxed to CDC.


Changed on 2/14/2017

VAERS ID: 292129 Before After
VAERS Form:
Age:0.5 0.49
Gender:Male
Location:Missouri
Vaccinated:2007-05-23
Onset:2007-09-04
Submitted:2007-10-03
Entered:2007-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B113AA / 3 LL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH BO8679F / 3 RL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 00030U / 3 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal distension, Barium enema, Computerised tomogram abnormal, Dehydration, Gastroenteritis, Haematochezia, Ileus, Inappropriate schedule of drug administration, Intestinal obstruction, Intussusception, Malaise, Pyrexia, Surgery, Vomiting, Explorative laparotomy, Intestinal anastomosis, Colectomy

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 14     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown LABS: BE revealed IS. CT of abdomen revealed bowel obstruction or severe ileus.
CDC 'Split Type': WAES0710USA00021

Write-up: Information has been received from a physician concerning a 10 month old patient (gender not reported) who on an unspecified date was vaccinated with the completed 3 dose series of Rotateq. Subsequently the patient experienced intussusception and was hospitalized. The intussusception was corrected surgically. On an unspecified date, the patient recovered from intussusception. Intussusception was considered to be immediately life-threatening. Additional information has been requested. 10/8/07 Patient demographics provided by CDC. 10/26/07 Received vax record & VAERS database updated w/same. Also received tag 2 report from pcp which included AE onset. Record faxed to CDC. 11/27/07 Reviewed hospital medical records which reveal patient experienced blood in stools, fever & vomiting x 2 days. Seen by pcp who dx w/gastroenteritis & sent home. Vomiting continued & taken to ER. Admitted 9/5-9/18/2007. He appeared dehydrated & ill. BE done revealed colocolic IS but not able to reduce. Taken to OR where exp laparotomy with right extended hemicolectomy w/primary anastomosis & re-exploration laparoscopically with open reduction of IS was done. Did well initially post operatively but on day 3-4 became distended & vomited. Continued for several days & unable to tolerate oral feeds. Taken back to OR where second IS was found & easily reduced. Progressed well after 2nd surgery & d/c to home. FINAL DX: Intussusception, recurrent, surgically reduced x 2 with hemicolectomy. Records faxed to CDC.


Changed on 4/14/2017

VAERS ID: 292129 Before After
VAERS Form:
Age:0.49
Gender:Male
Location:Missouri
Vaccinated:2007-05-23
Onset:2007-09-04
Submitted:2007-10-03
Entered:2007-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B113AA / 3 LL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH BO8679F / 3 RL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 00030U / 3 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal distension, Barium enema, Computerised tomogram abnormal, Dehydration, Gastroenteritis, Haematochezia, Ileus, Inappropriate schedule of drug administration, Intestinal obstruction, Intussusception, Malaise, Pyrexia, Surgery, Vomiting, Explorative laparotomy, Intestinal anastomosis, Colectomy

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 14     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown LABS: BE revealed IS. CT of abdomen revealed bowel obstruction or severe ileus.
CDC 'Split Type': WAES0710USA00021

Write-up: Information has been received from a physician concerning a 10 month old patient (gender not reported) who on an unspecified date was vaccinated with the completed 3 dose series of Rotateq. Subsequently the patient experienced intussusception and was hospitalized. The intussusception was corrected surgically. On an unspecified date, the patient recovered from intussusception. Intussusception was considered to be immediately life-threatening. Additional information has been requested. 10/8/07 Patient demographics provided by CDC. 10/26/07 Received vax record & VAERS database updated w/same. Also received tag 2 report from pcp which included AE onset. Record faxed to CDC. 11/27/07 Reviewed hospital medical records which reveal patient experienced blood in stools, fever & vomiting x 2 days. Seen by pcp who dx w/gastroenteritis & sent home. Vomiting continued & taken to ER. Admitted 9/5-9/18/2007. He appeared dehydrated & ill. BE done revealed colocolic IS but not able to reduce. Taken to OR where exp laparotomy with right extended hemicolectomy w/primary anastomosis & re-exploration laparoscopically with open reduction of IS was done. Did well initially post operatively but on day 3-4 became distended & vomited. Continued for several days & unable to tolerate oral feeds. Taken back to OR where second IS was found & easily reduced. Progressed well after 2nd surgery & d/c to home. FINAL DX: Intussusception, recurrent, surgically reduced x 2 with hemicolectomy. Records faxed to CDC.


Changed on 9/14/2017

VAERS ID: 292129 Before After
VAERS Form:(blank) 1
Age:0.49
Gender:Male
Location:Missouri
Vaccinated:2007-05-23
Onset:2007-09-04
Submitted:2007-10-03
Entered:2007-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B113AA / 3 4 LL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH BO8679F / 3 4 RL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 00030U / 3 4 - MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Inappropriate schedule of drug administration, 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)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 14     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown LABS: BE revealed IS. CT of abdomen revealed bowel obstruction or severe ileus.
CDC 'Split Type': WAES0710USA00021

Write-up: Information has been received from a physician concerning a 10 month old patient (gender not reported) who on an unspecified date was vaccinated with the completed 3 dose series of Rotateq. Subsequently the patient experienced intussusception and was hospitalized. The intussusception was corrected surgically. On an unspecified date, the patient recovered from intussusception. Intussusception was considered to be immediately life-threatening. Additional information has been requested. 10/8/07 Patient demographics provided by CDC. 10/26/07 Received vax record & VAERS database updated w/same. Also received tag 2 report from pcp which included AE onset. Record faxed to CDC. 11/27/07 Reviewed hospital medical records which reveal patient experienced blood in stools, fever & vomiting x 2 days. Seen by pcp who dx w/gastroenteritis & sent home. Vomiting continued & taken to ER. Admitted 9/5-9/18/2007. He appeared dehydrated & ill. BE done revealed colocolic IS but not able to reduce. Taken to OR where exp laparotomy with right extended hemicolectomy w/primary anastomosis & re-exploration laparoscopically with open reduction of IS was done. Did well initially post operatively but on day 3-4 became distended & vomited. Continued for several days & unable to tolerate oral feeds. Taken back to OR where second IS was found & easily reduced. Progressed well after 2nd surgery & d/c to home. FINAL DX: Intussusception, recurrent, surgically reduced x 2 with hemicolectomy. Records faxed to CDC.


Changed on 2/14/2018

VAERS ID: 292129 Before After
VAERS Form:1
Age:0.49
Gender:Male
Location:Missouri
Vaccinated:2007-05-23
Onset:2007-09-04
Submitted:2007-10-03
Entered:2007-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B113AA / 4 LL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH BO8679F / 4 RL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 00030U / 4 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Inappropriate schedule of drug administration, 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)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 14     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown LABS: BE revealed IS. CT of abdomen revealed bowel obstruction or severe ileus.
CDC 'Split Type': WAES0710USA00021

Write-up: Information has been received from a physician concerning a 10 month old patient (gender not reported) who on an unspecified date was vaccinated with the completed 3 dose series of Rotateq. Subsequently the patient experienced intussusception and was hospitalized. The intussusception was corrected surgically. On an unspecified date, the patient recovered from intussusception. Intussusception was considered to be immediately life-threatening. Additional information has been requested. 10/8/07 Patient demographics provided by CDC. 10/26/07 Received vax record & VAERS database updated w/same. Also received tag 2 report from pcp which included AE onset. Record faxed to CDC. 11/27/07 Reviewed hospital medical records which reveal patient experienced blood in stools, fever & vomiting x 2 days. Seen by pcp who dx w/gastroenteritis & sent home. Vomiting continued & taken to ER. Admitted 9/5-9/18/2007. He appeared dehydrated & ill. BE done revealed colocolic IS but not able to reduce. Taken to OR where exp laparotomy with right extended hemicolectomy w/primary anastomosis & re-exploration laparoscopically with open reduction of IS was done. Did well initially post operatively but on day 3-4 became distended & vomited. Continued for several days & unable to tolerate oral feeds. Taken back to OR where second IS was found & easily reduced. Progressed well after 2nd surgery & d/c to home. FINAL DX: Intussusception, recurrent, surgically reduced x 2 with hemicolectomy. Records faxed to CDC.


Changed on 6/14/2018

VAERS ID: 292129 Before After
VAERS Form:1
Age:0.49
Gender:Male
Location:Missouri
Vaccinated:2007-05-23
Onset:2007-09-04
Submitted:2007-10-03
Entered:2007-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B113AA / 4 LL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH BO8679F / 4 RL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 00030U / 4 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Inappropriate schedule of drug administration, 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)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 14     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown LABS: BE revealed IS. CT of abdomen revealed bowel obstruction or severe ileus.
CDC 'Split Type': WAES0710USA00021

Write-up: Information has been received from a physician concerning a 10 month old patient (gender not reported) who on an unspecified date was vaccinated with the completed 3 dose series of Rotateq. Subsequently the patient experienced intussusception and was hospitalized. The intussusception was corrected surgically. On an unspecified date, the patient recovered from intussusception. Intussusception was considered to be immediately life-threatening. Additional information has been requested. 10/8/07 Patient demographics provided by CDC. 10/26/07 Received vax record & VAERS database updated w/same. Also received tag 2 report from pcp which included AE onset. Record faxed to CDC. 11/27/07 Reviewed hospital medical records which reveal patient experienced blood in stools, fever & vomiting x 2 days. Seen by pcp who dx w/gastroenteritis & sent home. Vomiting continued & taken to ER. Admitted 9/5-9/18/2007. He appeared dehydrated & ill. BE done revealed colocolic IS but not able to reduce. Taken to OR where exp laparotomy with right extended hemicolectomy w/primary anastomosis & re-exploration laparoscopically with open reduction of IS was done. Did well initially post operatively but on day 3-4 became distended & vomited. Continued for several days & unable to tolerate oral feeds. Taken back to OR where second IS was found & easily reduced. Progressed well after 2nd surgery & d/c to home. FINAL DX: Intussusception, recurrent, surgically reduced x 2 with hemicolectomy. Records faxed to CDC.


Changed on 8/14/2018

VAERS ID: 292129 Before After
VAERS Form:1
Age:0.49
Gender:Male
Location:Missouri
Vaccinated:2007-05-23
Onset:2007-09-04
Submitted:2007-10-03
Entered:2007-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B113AA / 4 LL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH BO8679F / 4 RL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 00030U / 4 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Inappropriate schedule of drug administration, 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)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 14     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown LABS: BE revealed IS. CT of abdomen revealed bowel obstruction or severe ileus.
CDC 'Split Type': WAES0710USA00021

Write-up: Information has been received from a physician concerning a 10 month old patient (gender not reported) who on an unspecified date was vaccinated with the completed 3 dose series of Rotateq. Subsequently the patient experienced intussusception and was hospitalized. The intussusception was corrected surgically. On an unspecified date, the patient recovered from intussusception. Intussusception was considered to be immediately life-threatening. Additional information has been requested. 10/8/07 Patient demographics provided by CDC. 10/26/07 Received vax record & VAERS database updated w/same. Also received tag 2 report from pcp which included AE onset. Record faxed to CDC. 11/27/07 Reviewed hospital medical records which reveal patient experienced blood in stools, fever & vomiting x 2 days. Seen by pcp who dx w/gastroenteritis & sent home. Vomiting continued & taken to ER. Admitted 9/5-9/18/2007. He appeared dehydrated & ill. BE done revealed colocolic IS but not able to reduce. Taken to OR where exp laparotomy with right extended hemicolectomy w/primary anastomosis & re-exploration laparoscopically with open reduction of IS was done. Did well initially post operatively but on day 3-4 became distended & vomited. Continued for several days & unable to tolerate oral feeds. Taken back to OR where second IS was found & easily reduced. Progressed well after 2nd surgery & d/c to home. FINAL DX: Intussusception, recurrent, surgically reduced x 2 with hemicolectomy. Records faxed to CDC.


Changed on 9/14/2018

VAERS ID: 292129 Before After
VAERS Form:1
Age:0.49
Gender:Male
Location:Missouri
Vaccinated:2007-05-23
Onset:2007-09-04
Submitted:2007-10-03
Entered:2007-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B113AA / 4 LL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH BO8679F / 4 RL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 00030U / 4 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Inappropriate schedule of drug administration, 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)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 14     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown LABS: BE revealed IS. CT of abdomen revealed bowel obstruction or severe ileus.
CDC 'Split Type': WAES0710USA00021

Write-up: Information has been received from a physician concerning a 10 month old patient (gender not reported) who on an unspecified date was vaccinated with the completed 3 dose series of Rotateq. Subsequently the patient experienced intussusception and was hospitalized. The intussusception was corrected surgically. On an unspecified date, the patient recovered from intussusception. Intussusception was considered to be immediately life-threatening. Additional information has been requested. 10/8/07 Patient demographics provided by CDC. 10/26/07 Received vax record & VAERS database updated w/same. Also received tag 2 report from pcp which included AE onset. Record faxed to CDC. 11/27/07 Reviewed hospital medical records which reveal patient experienced blood in stools, fever & vomiting x 2 days. Seen by pcp who dx w/gastroenteritis & sent home. Vomiting continued & taken to ER. Admitted 9/5-9/18/2007. He appeared dehydrated & ill. BE done revealed colocolic IS but not able to reduce. Taken to OR where exp laparotomy with right extended hemicolectomy w/primary anastomosis & re-exploration laparoscopically with open reduction of IS was done. Did well initially post operatively but on day 3-4 became distended & vomited. Continued for several days & unable to tolerate oral feeds. Taken back to OR where second IS was found & easily reduced. Progressed well after 2nd surgery & d/c to home. FINAL DX: Intussusception, recurrent, surgically reduced x 2 with hemicolectomy. Records faxed to CDC.


Changed on 10/14/2018

VAERS ID: 292129 Before After
VAERS Form:1
Age:0.49
Gender:Male
Location:Missouri
Vaccinated:2007-05-23
Onset:2007-09-04
Submitted:2007-10-03
Entered:2007-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B113AA / 4 LL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH BO8679F / 4 RL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 00030U / 4 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Inappropriate schedule of drug administration, 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)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 14     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown LABS: BE revealed IS. CT of abdomen revealed bowel obstruction or severe ileus.
CDC 'Split Type': WAES0710USA00021

Write-up: Information has been received from a physician concerning a 10 month old patient (gender not reported) who on an unspecified date was vaccinated with the completed 3 dose series of Rotateq. Subsequently the patient experienced intussusception and was hospitalized. The intussusception was corrected surgically. On an unspecified date, the patient recovered from intussusception. Intussusception was considered to be immediately life-threatening. Additional information has been requested. 10/8/07 Patient demographics provided by CDC. 10/26/07 Received vax record & VAERS database updated w/same. Also received tag 2 report from pcp which included AE onset. Record faxed to CDC. 11/27/07 Reviewed hospital medical records which reveal patient experienced blood in stools, fever & vomiting x 2 days. Seen by pcp who dx w/gastroenteritis & sent home. Vomiting continued & taken to ER. Admitted 9/5-9/18/2007. He appeared dehydrated & ill. BE done revealed colocolic IS but not able to reduce. Taken to OR where exp laparotomy with right extended hemicolectomy w/primary anastomosis & re-exploration laparoscopically with open reduction of IS was done. Did well initially post operatively but on day 3-4 became distended & vomited. Continued for several days & unable to tolerate oral feeds. Taken back to OR where second IS was found & easily reduced. Progressed well after 2nd surgery & d/c to home. FINAL DX: Intussusception, recurrent, surgically reduced x 2 with hemicolectomy. Records faxed to CDC.

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