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This is VAERS ID 293965

Case Details

VAERS ID: 293965 (history)  
Form: Version 1.0  
Age: 0.5  
Gender: Male  
Location: Louisiana  
Vaccinated:2007-08-21
Onset:2007-09-01
   Days after vaccination:11
Submitted: 2007-10-19
   Days after onset:48
Entered: 2007-10-22
   Days after submission:3
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124AA / 3 UN / UN
HIBV: HIB (NO BRAND NAME) / UNKNOWN MANUFACTURER 1126F / 3 UN / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B58845F / 3 UN / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0875U / 3 MO / PO

Administered by: Other       Purchased by: Other
Symptoms: Barium enema, Diarrhoea, Enema administration, Flatulence, Intussusception, Mucous stools, Pyrexia, Rotavirus test negative, Screaming
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Pseudomembranous colitis (broad), Gastrointestinal obstruction (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hostility/aggression (broad), Noninfectious diarrhoea (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

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, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: barium enema X-ray 10/05/07 - "cleared the intussusception"; stool rotavirus RNA 09/12/07 negat LABS: BE reduced IS. LABS: WBC 16.1, H/H 12.5/34.8. Chemistry WNL.
CDC Split Type: WAES0710USA02336

Write-up: Information has been received from health professionals concerning a 7 month old male who received his first dose on 17-APR-2007, second dose 20-JUN-2007, and a third dose, 2 ml oral 21-AUG-2007, of Rotateq (lot #655866/1110F; 56385/0030U; 656381/0875U respectively). Concomitant vaccines included Hib conj vaccine (lot#''s53523/0063U and 654679/1126F respectively), PREVNAR (lot #''s B08691F; B08690H; and B58845F respectively), and PEDIARIX (lot #''s AC21B096A; AC21B114CA; and AC21B124AA respectively). On 11-SEP-2007, the patient''s mother phoned the office reporting that the patient had developed a fever, loose stools, was gassy, and was screaming every 1 1/2 hours at night. He was seen in the office and stool samples on 12-SEP-2007 were negative for Rota virus. The reporter stated that he continued to experience symptoms "on and off over the next couple of weeks." He was seen in the office again on 04-OCT-2007, after developing loose stools with mucous and low grade fever "on and off". On 05-OCT-2007, he was hospitalized and underwent an x-ray with barium enema "which cleared the intussusception". He was seen in the office in follow up to his hospitalization and reportedly was "doing fine". The reporter stated "the admission to the hospital and enema administration was intervention to prevent serious criteria". No product quality complaint was reported. The patients experiences were considered to be other important medical events by the reporter. This is one of two reports from the same source. Additional information has been requested. 10/23/07 Patient demographics provided by CDC. 10/23/07 Recieved contrast enema report from CDC which reveals patient had ileocolic IS at hepatic flexure & was successfully reduced. 10/23/07 Received vax record from pcp & VAERS database updated w/same. 12/4/07 Received ER medical records which reveal patient experienced irritability, fever & distended abdomen. BE reduced IS but transferred to higher level of care for continued observation. FINAL ER DX: Intussusception. Records faxed to CDC. 12/7/07 Reviewed hospital medical records which reveal patient experienced abdominal discomfort for approx 1 month starting w/ulcerations in mouth & throat & progressed to nightly abdominal pain, large amounts of gas, low grade fever intermittently. PCP tested for rotavirus which was neg. Initially had increased WBC. GI consult done as outpatient 1 week prior to admit who dx GERD, tx w/antacid & antibiotic. Transferred from outlying ER s/p BE revealed IS. Admitted 10/6 & d/c same day. To f/u w/PCP & have GI small bowel series done as outpatient. FINAL DX: abdominal pain, possible formula intolerance, unlikely intussusception. Records faxed to CDC.


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