This is VAERS ID 292396

History of Changes from the VAERS Wayback Machine

First Appeared on 12/31/2007

Vaccin­ation / Manu­facturer	Lot / Dose	Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR	02657AA / 0	RL / IM
HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC.	0016U / 0	LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR	21009 / 0	RA / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC	B53981B / 0	LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC.	0972U / 0	- / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Barium double contrast, Blood culture positive, Body temperature increased, Depressed level of consciousness, Enema administration

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: Abnormal hemoglobin; FAV Variant Barts. PMH: failed NB hearing screen.
Allergies:
Diagnostic Lab Data: Labs and Diagnostics: Air contrast enema (+) for Intussusception. Labs unremarkable.
CDC 'Split Type':

Write-up: Vaccine given 8/24/07. Started vomiting 9/23/07, no fever, no diarrhea initially - diagnosed with viral gastroenteritis. On 9/25/07 had large bloody bowel movement - seen in local ER, transferred to another hospital where diagnosed with intussusception an"d underwent surgical correction/resection. Hospital records received from PCP for DOS 9/26-30/2007 for DX Incarcerated Intussusception. Infant presented with lethargy, mental status changes, decreased po intake and a large bloody bowel movement. PE sig

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Changed on 12/8/2009

Vaccin­ation / Manu­facturer	Lot / Dose	Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR	02657AA / 0	RL / IM
HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC.	0016U / 0	LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR	21009 / 0	RA / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC	B53981B / 0	LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC.	0972U / 0	- / PO

Administered by: Private      Purchased by: Unknown Private
Symptoms: Barium double contrast, Blood culture positive, Body temperature increased, Depressed level of consciousness, Full blood count, Gastroenteritis viral, Haematochezia, Intussusception, Lethargy, Listless, Mucosal dryness, Small intestinal resection, Vomiting, White blood cell count decreased, Mental status changes, Enema administration, Explorative laparotomy, Oral intake reduced

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: Abnormal hemoglobin; FAV Variant Barts. PMH: failed NB hearing screen.
Allergies:
Diagnostic Lab Data: Labs and Diagnostics: Air contrast enema (+) for Intussusception. Labs unremarkable. CBC with 3.7 WBCs. Blood culture (+) Gram (+) cocci in clusters-Staphylococcus species. Surgical pathology of bowel segment shows ulcerated areas with perforation
CDC 'Split Type':

Write-up: Vaccine given 8/24/07. Started vomiting 9/23/07, no fever, no diarrhea initially - diagnosed with viral gastroenteritis. On 9/25/07 had large bloody bowel movement - seen in local ER, transferred to another hospital where diagnosed with intussusception an"d and underwent surgical correction/resection. Hospital records received from PCP for DOS 9/26-30/2007 for DX Incarcerated Intussusception. Infant presented with lethargy, mental status changes, decreased po intake and a large bloody bowel movement. PE sig significant for T=100.6''F, listness and acutely ill appearing, dry mucus membranes, minimal response to painful stimuli, rectal exam (+) for gross blood. Reduction failed by air contrast enema and infant taken to OR for Exploratory Lap with small bowel resection for IS. Pt tolerated advancing diet and was d/c home on 9/30/2007. 10/23/2007 Vax record received and correlates with VAERS submission. Per 60 day follow up: Patient underwent exploratory laparotomy with small bowel resection for incarcerated intussusception.

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Changed on 3/2/2010

Vaccin­ation / Manu­facturer	Lot / Dose	Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR	02657AA / 0	RL / IM
HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC.	0016U / 0	LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR	21009 / 0	RA / IM
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC	B53981B / 0	LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC.	0972U / 0	- / PO

Administered by: Private      Purchased by: Private
Symptoms: Barium double contrast, Blood culture positive, Body temperature increased, Depressed level of consciousness, Full blood count, Gastroenteritis viral, Haematochezia, Intussusception, Lethargy, Listless, Mucosal dryness, Small intestinal resection, Vomiting, White blood cell count decreased, Mental status changes, Enema administration, Explorative laparotomy, Oral intake reduced

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: Abnormal hemoglobin; FAV Variant Barts. PMH: failed NB hearing screen.
Allergies:
Diagnostic Lab Data: Labs and Diagnostics: Air contrast enema (+) for Intussusception. CBC with 3.7 WBCs. Blood culture (+) Gram (+) cocci in clusters-Staphylococcus species. Surgical pathology of bowel segment shows ulcerated areas with perforation
CDC 'Split Type':

Write-up: Vaccine given 8/24/07. Started vomiting 9/23/07, no fever, no diarrhea initially - diagnosed with viral gastroenteritis. On 9/25/07 had large bloody bowel movement - seen in local ER, transferred to another hospital where diagnosed with intussusception and underwent surgical correction/resection. Hospital records received from PCP for DOS 9/26-30/2007 for DX Incarcerated Intussusception. Infant presented with lethargy, mental status changes, decreased po intake and a large bloody bowel movement. PE significant for T=100.6''F, listness and acutely ill appearing, dry mucus membranes, minimal response to painful stimuli, rectal exam (+) for gross blood. Reduction failed by air contrast enema and infant taken to OR for Exploratory Lap with small bowel resection for IS. Pt tolerated advancing diet and was d/c home on 9/30/2007. 10/23/2007 Vax record received and correlates with VAERS submission. Per 60 day follow up: Patient underwent exploratory laparotomy with small bowel resection for incarcerated intussusception.

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Changed on 4/7/2010

Vaccin­ation / Manu­facturer	Lot / Dose	Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR	02657AA / 0	RL / IM
HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC.	0016U / 0	LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR	21009 / 0	RA / IM
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC	B53981B / 0	LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC.	0972U / 0	- / PO

Administered by: Private      Purchased by: Private
Symptoms: Barium double contrast, Blood culture positive, Body temperature increased, Depressed level of consciousness, Full blood count, Gastroenteritis viral, Haematochezia, Intussusception, Lethargy, Listless, Mucosal dryness, Small intestinal resection, Vomiting, White blood cell count decreased, Mental status changes, Enema administration, Explorative laparotomy, Oral intake reduced

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: Abnormal hemoglobin; FAV Variant Barts. PMH: failed NB hearing screen.
Allergies:
Diagnostic Lab Data: Labs and Diagnostics: Air contrast enema (+) for Intussusception. CBC with 3.7 WBCs. Blood culture (+) Gram (+) cocci in clusters-Staphylococcus species. Surgical pathology of bowel segment shows ulcerated areas with perforation
CDC 'Split Type':

Write-up: Vaccine given 8/24/07. Started vomiting 9/23/07, no fever, no diarrhea initially - diagnosed with viral gastroenteritis. On 9/25/07 had large bloody bowel movement - seen in local ER, transferred to another hospital where diagnosed with intussusception and underwent surgical correction/resection. Hospital records received from PCP for DOS 9/26-30/2007 for DX Incarcerated Intussusception. Infant presented with lethargy, mental status changes, decreased po intake and a large bloody bowel movement. PE significant for T=100.6''F, listness and acutely ill appearing, dry mucus membranes, minimal response to painful stimuli, rectal exam (+) for gross blood. Reduction failed by air contrast enema and infant taken to OR for Exploratory Lap with small bowel resection for IS. Pt tolerated advancing diet and was d/c home on 9/30/2007. 10/23/2007 Vax record received and correlates with VAERS submission. Per 60 day follow up: Patient underwent exploratory laparotomy with small bowel resection for incarcerated intussusception.

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Changed on 8/31/2010

Vaccin­ation / Manu­facturer	Lot / Dose	Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR	02657AA / 0	RL / IM
HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC.	0016U / 0	LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR	21009 / 0	RA / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH	B53981B / 0	LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC.	0972U / 0	- / PO

Administered by: Private      Purchased by: Private
Symptoms: Barium double contrast, Blood culture positive, Body temperature increased, Depressed level of consciousness, Full blood count, Gastroenteritis viral, Haematochezia, Intussusception, Lethargy, Listless, Mucosal dryness, Small intestinal resection, Vomiting, White blood cell count decreased, Mental status changes, Enema administration, Explorative laparotomy, Oral intake reduced

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: Abnormal hemoglobin; FAV Variant Barts. PMH: failed NB hearing screen.
Allergies:
Diagnostic Lab Data: Labs and Diagnostics: Air contrast enema (+) for Intussusception. CBC with 3.7 WBCs. Blood culture (+) Gram (+) cocci in clusters-Staphylococcus species. Surgical pathology of bowel segment shows ulcerated areas with perforation
CDC 'Split Type':

Write-up: Vaccine given 8/24/07. Started vomiting 9/23/07, no fever, no diarrhea initially - diagnosed with viral gastroenteritis. On 9/25/07 had large bloody bowel movement - seen in local ER, transferred to another hospital where diagnosed with intussusception and underwent surgical correction/resection. Hospital records received from PCP for DOS 9/26-30/2007 for DX Incarcerated Intussusception. Infant presented with lethargy, mental status changes, decreased po intake and a large bloody bowel movement. PE significant for T=100.6''F, listness and acutely ill appearing, dry mucus membranes, minimal response to painful stimuli, rectal exam (+) for gross blood. Reduction failed by air contrast enema and infant taken to OR for Exploratory Lap with small bowel resection for IS. Pt tolerated advancing diet and was d/c home on 9/30/2007. 10/23/2007 Vax record received and correlates with VAERS submission. Per 60 day follow up: Patient underwent exploratory laparotomy with small bowel resection for incarcerated intussusception.

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Changed on 5/13/2013

Vaccin­ation / Manu­facturer	Lot / Dose	Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR	02657AA / 0	RL / IM
HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC.	0016U / 0	LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR	21009 / 0	RA / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH	B53981B / 0	LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC.	0972U / 0	- / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC.	0972U / 0	- / PO

Administered by: Private      Purchased by: Private
Symptoms: Barium double contrast, Blood culture positive, Body temperature increased, Depressed level of consciousness, Full blood count, Gastroenteritis viral, Haematochezia, Intussusception, Lethargy, Listless, Mucosal dryness, Small intestinal resection, Vomiting, White blood cell count decreased, Mental status changes, Enema administration, Explorative laparotomy, Oral intake reduced

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: Abnormal hemoglobin; FAV Variant Barts. PMH: failed NB hearing screen.
Allergies:
Diagnostic Lab Data: Labs and Diagnostics: Air contrast enema (+) for Intussusception. CBC with 3.7 WBCs. Blood culture (+) Gram (+) cocci in clusters-Staphylococcus species. Surgical pathology of bowel segment shows ulcerated areas with perforation
CDC 'Split Type':

Write-up: Vaccine given 8/24/07. Started vomiting 9/23/07, no fever, no diarrhea initially - diagnosed with viral gastroenteritis. On 9/25/07 had large bloody bowel movement - seen in local ER, transferred to another hospital where diagnosed with intussusception and underwent surgical correction/resection. Hospital records received from PCP for DOS 9/26-30/2007 for DX Incarcerated Intussusception. Infant presented with lethargy, mental status changes, decreased po intake and a large bloody bowel movement. PE significant for T=100.6''F, listness and acutely ill appearing, dry mucus membranes, minimal response to painful stimuli, rectal exam (+) for gross blood. Reduction failed by air contrast enema and infant taken to OR for Exploratory Lap with small bowel resection for IS. Pt tolerated advancing diet and was d/c home on 9/30/2007. 10/23/2007 Vax record received and correlates with VAERS submission. Per 60 day follow up: Patient underwent exploratory laparotomy with small bowel resection for incarcerated intussusception.

---

Changed on 4/14/2017

Vaccin­ation / Manu­facturer	Lot / Dose	Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR	02657AA / 0	RL / IM
HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC.	0016U / 0	LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR	21009 / 0	RA / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH	B53981B / 0	LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC.	0972U / 0	- / PO

Administered by: Private      Purchased by: Private
Symptoms: Barium double contrast, Blood culture positive, Body temperature increased, Depressed level of consciousness, Full blood count, Gastroenteritis viral, Haematochezia, Intussusception, Lethargy, Listless, Mucosal dryness, Small intestinal resection, Vomiting, White blood cell count decreased, Mental status changes, Enema administration, Explorative laparotomy, Oral intake reduced

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: Abnormal hemoglobin; FAV Variant Barts. PMH: failed NB hearing screen.
Allergies:
Diagnostic Lab Data: Labs and Diagnostics: Air contrast enema (+) for Intussusception. CBC with 3.7 WBCs. Blood culture (+) Gram (+) cocci in clusters-Staphylococcus species. Surgical pathology of bowel segment shows ulcerated areas with perforation
CDC 'Split Type':

Write-up: Vaccine given 8/24/07. Started vomiting 9/23/07, no fever, no diarrhea initially - diagnosed with viral gastroenteritis. On 9/25/07 had large bloody bowel movement - seen in local ER, transferred to another hospital where diagnosed with intussusception and underwent surgical correction/resection. Hospital records received from PCP for DOS 9/26-30/2007 for DX Incarcerated Intussusception. Infant presented with lethargy, mental status changes, decreased po intake and a large bloody bowel movement. PE significant for T=100.6''F, listness and acutely ill appearing, dry mucus membranes, minimal response to painful stimuli, rectal exam (+) for gross blood. Reduction failed by air contrast enema and infant taken to OR for Exploratory Lap with small bowel resection for IS. Pt tolerated advancing diet and was d/c home on 9/30/2007. 10/23/2007 Vax record received and correlates with VAERS submission. Per 60 day follow up: Patient underwent exploratory laparotomy with small bowel resection for incarcerated intussusception.

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Changed on 9/14/2017

Vaccin­ation / Manu­facturer	Lot / Dose	Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR	02657AA / 0 1	RL / IM
HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC.	0016U / 0 1	LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR	21009 / 0 1	RA / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH	B53981B / 0 1	LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC.	0972U / 0 1	- MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Gastroenteritis viral, Haematochezia, Intussusception, Vomiting

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: Abnormal hemoglobin; FAV Variant Barts. PMH: failed NB hearing screen.
Allergies:
Diagnostic Lab Data: Labs and Diagnostics: Air contrast enema (+) for Intussusception. CBC with 3.7 WBCs. Blood culture (+) Gram (+) cocci in clusters-Staphylococcus species. Surgical pathology of bowel segment shows ulcerated areas with perforation
CDC 'Split Type':

Write-up: Vaccine given 8/24/07. Started vomiting 9/23/07, no fever, no diarrhea initially - diagnosed with viral gastroenteritis. On 9/25/07 had large bloody bowel movement - seen in local ER, transferred to another hospital where diagnosed with intussusception and underwent surgical correction/resection. Hospital records received from PCP for DOS 9/26-30/2007 for DX Incarcerated Intussusception. Infant presented with lethargy, mental status changes, decreased po intake and a large bloody bowel movement. PE significant for T=100.6''F, listness and acutely ill appearing, dry mucus membranes, minimal response to painful stimuli, rectal exam (+) for gross blood. Reduction failed by air contrast enema and infant taken to OR for Exploratory Lap with small bowel resection for IS. Pt tolerated advancing diet and was d/c home on 9/30/2007. 10/23/2007 Vax record received and correlates with VAERS submission. Per 60 day follow up: Patient underwent exploratory laparotomy with small bowel resection for incarcerated intussusception.

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Changed on 2/14/2018

Vaccin­ation / Manu­facturer	Lot / Dose	Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR	02657AA / 1	RL / IM
HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC.	0016U / 1	LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR	21009 / 1	RA / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH	B53981B / 1	LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC.	0972U / 1	MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Gastroenteritis viral, Haematochezia, Intussusception, Vomiting

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: Abnormal hemoglobin; FAV Variant Barts. PMH: failed NB hearing screen.
Allergies:
Diagnostic Lab Data: Labs and Diagnostics: Air contrast enema (+) for Intussusception. CBC with 3.7 WBCs. Blood culture (+) Gram (+) cocci in clusters-Staphylococcus species. Surgical pathology of bowel segment shows ulcerated areas with perforation
CDC 'Split Type':

Write-up: Vaccine given 8/24/07. Started vomiting 9/23/07, no fever, no diarrhea initially - diagnosed with viral gastroenteritis. On 9/25/07 had large bloody bowel movement - seen in local ER, transferred to another hospital where diagnosed with intussusception and underwent surgical correction/resection. Hospital records received from PCP for DOS 9/26-30/2007 for DX Incarcerated Intussusception. Infant presented with lethargy, mental status changes, decreased po intake and a large bloody bowel movement. PE significant for T=100.6''F, listness and acutely ill appearing, dry mucus membranes, minimal response to painful stimuli, rectal exam (+) for gross blood. Reduction failed by air contrast enema and infant taken to OR for Exploratory Lap with small bowel resection for IS. Pt tolerated advancing diet and was d/c home on 9/30/2007. 10/23/2007 Vax record received and correlates with VAERS submission. Per 60 day follow up: Patient underwent exploratory laparotomy with small bowel resection for incarcerated intussusception.

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Changed on 6/14/2018

Vaccin­ation / Manu­facturer	Lot / Dose	Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR	02657AA / 1	RL / IM
HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC.	0016U / 1	LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR	21009 / 1	RA / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH	B53981B / 1	LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC.	0972U / 1	MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Gastroenteritis viral, Haematochezia, Intussusception, Vomiting

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: Abnormal hemoglobin; FAV Variant Barts. PMH: failed NB hearing screen.
Allergies:
Diagnostic Lab Data: Labs and Diagnostics: Air contrast enema (+) for Intussusception. CBC with 3.7 WBCs. Blood culture (+) Gram (+) cocci in clusters-Staphylococcus species. Surgical pathology of bowel segment shows ulcerated areas with perforation
CDC 'Split Type':

Write-up: Vaccine given 8/24/07. Started vomiting 9/23/07, no fever, no diarrhea initially - diagnosed with viral gastroenteritis. On 9/25/07 had large bloody bowel movement - seen in local ER, transferred to another hospital where diagnosed with intussusception and underwent surgical correction/resection. Hospital records received from PCP for DOS 9/26-30/2007 for DX Incarcerated Intussusception. Infant presented with lethargy, mental status changes, decreased po intake and a large bloody bowel movement. PE significant for T=100.6''F, listness and acutely ill appearing, dry mucus membranes, minimal response to painful stimuli, rectal exam (+) for gross blood. Reduction failed by air contrast enema and infant taken to OR for Exploratory Lap with small bowel resection for IS. Pt tolerated advancing diet and was d/c home on 9/30/2007. 10/23/2007 Vax record received and correlates with VAERS submission. Per 60 day follow up: Patient underwent exploratory laparotomy with small bowel resection for incarcerated intussusception.

---

Changed on 8/14/2018

Vaccin­ation / Manu­facturer	Lot / Dose	Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR	02657AA / 1	RL / IM
HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC.	0016U / 1	LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR	21009 / 1	RA / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH	B53981B / 1	LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC.	0972U / 1	MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Gastroenteritis viral, Haematochezia, Intussusception, Vomiting

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: Abnormal hemoglobin; FAV Variant Barts. PMH: failed NB hearing screen.
Allergies:
Diagnostic Lab Data: Labs and Diagnostics: Air contrast enema (+) for Intussusception. CBC with 3.7 WBCs. Blood culture (+) Gram (+) cocci in clusters-Staphylococcus species. Surgical pathology of bowel segment shows ulcerated areas with perforation
CDC 'Split Type':

Write-up: Vaccine given 8/24/07. Started vomiting 9/23/07, no fever, no diarrhea initially - diagnosed with viral gastroenteritis. On 9/25/07 had large bloody bowel movement - seen in local ER, transferred to another hospital where diagnosed with intussusception and underwent surgical correction/resection. Hospital records received from PCP for DOS 9/26-30/2007 for DX Incarcerated Intussusception. Infant presented with lethargy, mental status changes, decreased po intake and a large bloody bowel movement. PE significant for T=100.6''F, listness and acutely ill appearing, dry mucus membranes, minimal response to painful stimuli, rectal exam (+) for gross blood. Reduction failed by air contrast enema and infant taken to OR for Exploratory Lap with small bowel resection for IS. Pt tolerated advancing diet and was d/c home on 9/30/2007. 10/23/2007 Vax record received and correlates with VAERS submission. Per 60 day follow up: Patient underwent exploratory laparotomy with small bowel resection for incarcerated intussusception.

---

Changed on 9/14/2018

Vaccin­ation / Manu­facturer	Lot / Dose	Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR	02657AA / 1	RL / IM
HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC.	0016U / 1	LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR	21009 / 1	RA / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH	B53981B / 1	LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC.	0972U / 1	MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Gastroenteritis viral, Haematochezia, Intussusception, Vomiting

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: Abnormal hemoglobin; FAV Variant Barts. PMH: failed NB hearing screen.
Allergies:
Diagnostic Lab Data: Labs and Diagnostics: Air contrast enema (+) for Intussusception. CBC with 3.7 WBCs. Blood culture (+) Gram (+) cocci in clusters-Staphylococcus species. Surgical pathology of bowel segment shows ulcerated areas with perforation
CDC 'Split Type':

Write-up: Vaccine given 8/24/07. Started vomiting 9/23/07, no fever, no diarrhea initially - diagnosed with viral gastroenteritis. On 9/25/07 had large bloody bowel movement - seen in local ER, transferred to another hospital where diagnosed with intussusception and underwent surgical correction/resection. Hospital records received from PCP for DOS 9/26-30/2007 for DX Incarcerated Intussusception. Infant presented with lethargy, mental status changes, decreased po intake and a large bloody bowel movement. PE significant for T=100.6''F, listness and acutely ill appearing, dry mucus membranes, minimal response to painful stimuli, rectal exam (+) for gross blood. Reduction failed by air contrast enema and infant taken to OR for Exploratory Lap with small bowel resection for IS. Pt tolerated advancing diet and was d/c home on 9/30/2007. 10/23/2007 Vax record received and correlates with VAERS submission. Per 60 day follow up: Patient underwent exploratory laparotomy with small bowel resection for incarcerated intussusception.

---

Changed on 10/14/2018

Vaccin­ation / Manu­facturer	Lot / Dose	Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR	02657AA / 1	RL / IM
HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC.	0016U / 1	LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR	21009 / 1	RA / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH	B53981B / 1	LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC.	0972U / 1	MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Gastroenteritis viral, Haematochezia, Intussusception, Vomiting

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: Abnormal hemoglobin; FAV Variant Barts. PMH: failed NB hearing screen.
Allergies:
Diagnostic Lab Data: Labs and Diagnostics: Air contrast enema (+) for Intussusception. CBC with 3.7 WBCs. Blood culture (+) Gram (+) cocci in clusters-Staphylococcus species. Surgical pathology of bowel segment shows ulcerated areas with perforation
CDC 'Split Type':

Write-up: Vaccine given 8/24/07. Started vomiting 9/23/07, no fever, no diarrhea initially - diagnosed with viral gastroenteritis. On 9/25/07 had large bloody bowel movement - seen in local ER, transferred to another hospital where diagnosed with intussusception and underwent surgical correction/resection. Hospital records received from PCP for DOS 9/26-30/2007 for DX Incarcerated Intussusception. Infant presented with lethargy, mental status changes, decreased po intake and a large bloody bowel movement. PE significant for T=100.6''F, listness and acutely ill appearing, dry mucus membranes, minimal response to painful stimuli, rectal exam (+) for gross blood. Reduction failed by air contrast enema and infant taken to OR for Exploratory Lap with small bowel resection for IS. Pt tolerated advancing diet and was d/c home on 9/30/2007. 10/23/2007 Vax record received and correlates with VAERS submission. Per 60 day follow up: Patient underwent exploratory laparotomy with small bowel resection for incarcerated intussusception.

---

Changed on 12/24/2020

Vaccin­ation / Manu­facturer	Lot / Dose	Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR	02657AA / 1	RL / IM
HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC.	0016U / 1	LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR	21009 / 1	RA / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH	B53981B / 1	LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC.	0972U / 1	MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Gastroenteritis viral, Haematochezia, Intussusception, Vomiting

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: Abnormal hemoglobin; FAV Variant Barts. PMH: failed NB hearing screen.
Allergies:
Diagnostic Lab Data: Labs and Diagnostics: Air contrast enema (+) for Intussusception. CBC with 3.7 WBCs. Blood culture (+) Gram (+) cocci in clusters-Staphylococcus species. Surgical pathology of bowel segment shows ulcerated areas with perforation
CDC 'Split Type':

Write-up: Vaccine given 8/24/07. Started vomiting 9/23/07, no fever, no diarrhea initially - diagnosed with viral gastroenteritis. On 9/25/07 had large bloody bowel movement - seen in local ER, transferred to another hospital where diagnosed with intussusception and underwent surgical correction/resection. Hospital records received from PCP for DOS 9/26-30/2007 for DX Incarcerated Intussusception. Infant presented with lethargy, mental status changes, decreased po intake and a large bloody bowel movement. PE significant for T=100.6''F, listness and acutely ill appearing, dry mucus membranes, minimal response to painful stimuli, rectal exam (+) for gross blood. Reduction failed by air contrast enema and infant taken to OR for Exploratory Lap with small bowel resection for IS. Pt tolerated advancing diet and was d/c home on 9/30/2007. 10/23/2007 Vax record received and correlates with VAERS submission. Per 60 day follow up: Patient underwent exploratory laparotomy with small bowel resection for incarcerated intussusception.

---

Changed on 12/30/2020

Vaccin­ation / Manu­facturer	Lot / Dose	Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR	02657AA / 1	RL / IM
HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC.	0016U / 1	LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR	21009 / 1	RA / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH	B53981B / 1	LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC.	0972U / 1	MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Gastroenteritis viral, Haematochezia, Intussusception, Vomiting

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: Abnormal hemoglobin; FAV Variant Barts. PMH: failed NB hearing screen.
Allergies:
Diagnostic Lab Data: Labs and Diagnostics: Air contrast enema (+) for Intussusception. CBC with 3.7 WBCs. Blood culture (+) Gram (+) cocci in clusters-Staphylococcus species. Surgical pathology of bowel segment shows ulcerated areas with perforation
CDC 'Split Type':

Write-up: Vaccine given 8/24/07. Started vomiting 9/23/07, no fever, no diarrhea initially - diagnosed with viral gastroenteritis. On 9/25/07 had large bloody bowel movement - seen in local ER, transferred to another hospital where diagnosed with intussusception and underwent surgical correction/resection. Hospital records received from PCP for DOS 9/26-30/2007 for DX Incarcerated Intussusception. Infant presented with lethargy, mental status changes, decreased po intake and a large bloody bowel movement. PE significant for T=100.6''F, listness and acutely ill appearing, dry mucus membranes, minimal response to painful stimuli, rectal exam (+) for gross blood. Reduction failed by air contrast enema and infant taken to OR for Exploratory Lap with small bowel resection for IS. Pt tolerated advancing diet and was d/c home on 9/30/2007. 10/23/2007 Vax record received and correlates with VAERS submission. Per 60 day follow up: Patient underwent exploratory laparotomy with small bowel resection for incarcerated intussusception.

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