| VAERS ID: |
292561 (history) |
| Form: |
Version 1.0 |
| Age: |
0.5 |
| Sex: |
Male |
| Location: |
South Carolina |
| Vaccinated: | 2007-10-02 |
| Onset: | 2007-10-05 |
| Days after vaccination: | 3 |
| Submitted: |
0000-00-00 |
| Entered: |
2007-10-10 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS |
AC21B115CB / 3 |
LL / IM |
| FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR |
U2435AA / 1 |
LL / IM |
| HIBV: HIB (ACTHIB) / SANOFI PASTEUR |
UF119AA / 3 |
RL / IM |
| PNC: PNEUMO (PREVNAR) / PFIZER/WYETH |
B47300F / 3 |
RL / IM |
| RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. |
0410U / 3 |
MO / PO |
Administered by: Private Purchased by: Public
Symptoms: Abdominal X-ray,
Intussusception,
Urinary system X-ray
SMQs:, Gastrointestinal obstruction (narrow)
Life Threatening? No
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:
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Abdominal Xray, Abdominal KUB 10/22/07-records received-KUB showed dilated loops of bowel with air fluid levels. Ultrasound diagnostic for intussusception. 11/15/07-records received-11/15/07-tissue slide report received: specimen appendix.IHC for adenovirus positive. IHC for Rotavirus A negative.
CDC Split Type:
Write-up: intussusception confirmed by abdominal x ray, abdominal ultrasound at 10-5-07 10/22/07-records received for DOS 10/5-10/7/07-DC DX: Intussusception. Laparotomy, appendectomy. Operative reduction of intussusception. Hydrostatically irreducible. Three days prior to admission C/O abdominal pain and emesis, HX of episodic pain, no bloody bowel movements. | 