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This is VAERS ID 294388

History of Changes from the VAERS Wayback Machine

First Appeared on 12/31/2007

VAERS ID: 294388
VAERS Form:
Age:0.5
Gender:Male
Location:Nebraska
Vaccinated:2007-07-25
Onset:2007-10-04
Submitted:2007-10-24
Entered:2007-10-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2657AA / 2 UN / UN
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z1069 / 2 UN / UN
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B58845H / 2 UN / UN
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0875U / 2 - / PO

Administered by: Other      Purchased by: Unknown
Symptoms: Barium enema, Barium enema abnormal, Dehydration, Enema administration, Abdominal X-ray

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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: AXID
Current Illness: Gastrooesophageal reflux; Medical diet
Preexisting Conditions: PMH: viral infection w/fever 1 week prior to admit & rash 3 days prior to admit. Otitis media 2 weeks prior to admit. GERD.
Allergies:
Diagnostic Lab Data: diagnostic laboratory; abdominal X-ray; barium enema X-ray
CDC 'Split Type':

Write-up: Information has been received from a physician concerning an 8 month old male with reflux and history of /"MSPI type/" diet with no other medical history or drug allergies who on 22-MAR-2007, 24-MAY-2007 and 25-JUL-2007 was vaccinated PO with his first, s"econd and third doses (lot# 656381/0875U) of Rotateq. Concomitant vaccinations administered on 25-JUL-2007 included a dose of DTaP, a dose of poliovirus vaccine inactivated (unspecified) and a dose of (Prevnar). Other concomitant drug therapy included niz


Changed on 12/8/2009

VAERS ID: 294388 Before After
VAERS Form:
Age:0.5
Gender:Male
Location:Nebraska
Vaccinated:2007-07-25
Onset:2007-10-04
Submitted:2007-10-24
Entered:2007-10-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2657AA / 2 UN / UN
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z1069 / 2 UN / UN
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B58845H / 2 UN / UN
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0875U / 2 - / PO

Administered by: Other      Purchased by: Unknown Other
Symptoms: Barium enema, Barium enema abnormal, Dehydration, Full blood count normal, Haematochezia, Intussusception, Laboratory test abnormal, Lethargy, Rash, Small intestinal obstruction, Vomiting, X-ray with contrast upper gastrointestinal tract, Enema administration, Urine output decreased, Abdominal X-ray, 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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: AXID
Current Illness: Gastrooesophageal reflux; Medical diet
Preexisting Conditions: PMH: viral infection w/fever 1 week prior to admit & rash 3 days prior to admit. Otitis media 2 weeks prior to admit. GERD.
Allergies:
Diagnostic Lab Data: diagnostic laboratory; abdominal X-ray; barium enema X-ray LABS: CBC WNL. Chemistry revealed dehydration. Abdominal x-ray revealed SBO. UGI WNL. Barium enema revealed mid-transverse colon IS & reduced.
CDC 'Split Type': (blank) WAES0710USA03475

Write-up: Information has been received from a physician concerning an 8 month old male with reflux and history of /"MSPI type/" "MSPI type" diet with no other medical history or drug allergies who on 22-MAR-2007, 24-MAY-2007 and 25-JUL-2007 was vaccinated PO with his first, s"econd second and third doses (lot# 656381/0875U) of Rotateq. Concomitant vaccinations administered on 25-JUL-2007 included a dose of DTaP, a dose of poliovirus vaccine inactivated (unspecified) and a dose of (Prevnar). Other concomitant drug therapy included niz nizatidine (AXID) drops for reflux. On 04-OCT-2007 the patient experienced intussusception and was hospitalized. Medical attention was sought through the physician. Labs and abdominal x-rays were performed. A barium enema was also performed to reduce the intussusception. Subsequently, the patient recovered. There was no product quality complaint. Additional information has been requested. 10/26/07 Patient demographics provided by CDC. 10/30/07 Reviewed vax records which confirms RO dose & lot as reported & provides other vax info. VAERS database updated w/same. 11/2/07 Received hospital medical records which reveal patient experienced bilious vomiting x 2 days & 1 episode of bloody stool. Seen by pcp, sent to ER when vomiting persisted. Admitted 10/4-10/5/2007. Noted to have exanthem, lethargy, reduced oral intake & urine output. Progressed well s/p enema reduction & d/c to home. FINAL DX: Intussusception, enema reduced. Records faxed to CDC.


Changed on 3/2/2010

VAERS ID: 294388 Before After
VAERS Form:
Age:0.5
Gender:Male
Location:Nebraska
Vaccinated:2007-07-25
Onset:2007-10-04
Submitted:2007-10-24
Entered:2007-10-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2657AA / 2 UN / UN
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z1069 / 2 UN / UN
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC B58845H / 2 UN / UN
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0875U / 2 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium enema, Barium enema abnormal, Dehydration, Full blood count normal, Haematochezia, Intussusception, Laboratory test abnormal, Lethargy, Rash, Small intestinal obstruction, Vomiting, X-ray with contrast upper gastrointestinal tract, Enema administration, Urine output decreased, Abdominal X-ray, 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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: AXID
Current Illness: Gastrooesophageal reflux; Medical diet
Preexisting Conditions: PMH: viral infection w/fever 1 week prior to admit & rash 3 days prior to admit. Otitis media 2 weeks prior to admit. GERD.
Allergies:
Diagnostic Lab Data: diagnostic laboratory; abdominal X-ray; barium enema X-ray LABS: CBC WNL. Chemistry revealed dehydration. Abdominal x-ray revealed SBO. UGI WNL. Barium enema revealed mid-transverse colon IS & reduced.
CDC 'Split Type': WAES0710USA03475

Write-up: Information has been received from a physician concerning an 8 month old male with reflux and history of "MSPI type" diet with no other medical history or drug allergies who on 22-MAR-2007, 24-MAY-2007 and 25-JUL-2007 was vaccinated PO with his first, second and third doses (lot# 656381/0875U) of Rotateq. Concomitant vaccinations administered on 25-JUL-2007 included a dose of DTaP, a dose of poliovirus vaccine inactivated (unspecified) and a dose of (Prevnar). Other concomitant drug therapy included nizatidine (AXID) drops for reflux. On 04-OCT-2007 the patient experienced intussusception and was hospitalized. Medical attention was sought through the physician. Labs and abdominal x-rays were performed. A barium enema was also performed to reduce the intussusception. Subsequently, the patient recovered. There was no product quality complaint. Additional information has been requested. 10/26/07 Patient demographics provided by CDC. 10/30/07 Reviewed vax records which confirms RO dose & lot as reported & provides other vax info. VAERS database updated w/same. 11/2/07 Received hospital medical records which reveal patient experienced bilious vomiting x 2 days & 1 episode of bloody stool. Seen by pcp, sent to ER when vomiting persisted. Admitted 10/4-10/5/2007. Noted to have exanthem, lethargy, reduced oral intake & urine output. Progressed well s/p enema reduction & d/c to home. FINAL DX: Intussusception, enema reduced. Records faxed to CDC.


Changed on 4/7/2010

VAERS ID: 294388 Before After
VAERS Form:
Age:0.5
Gender:Male
Location:Nebraska
Vaccinated:2007-07-25
Onset:2007-10-04
Submitted:2007-10-24
Entered:2007-10-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2657AA / 2 UN / UN
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z1069 / 2 UN / UN
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B58845H / 2 UN / UN
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0875U / 2 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium enema, Barium enema abnormal, Dehydration, Full blood count normal, Haematochezia, Intussusception, Laboratory test abnormal, Lethargy, Rash, Small intestinal obstruction, Vomiting, X-ray with contrast upper gastrointestinal tract, Enema administration, Urine output decreased, Abdominal X-ray, 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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: AXID
Current Illness: Gastrooesophageal reflux; Medical diet
Preexisting Conditions: PMH: viral infection w/fever 1 week prior to admit & rash 3 days prior to admit. Otitis media 2 weeks prior to admit. GERD.
Allergies:
Diagnostic Lab Data: diagnostic laboratory; abdominal X-ray; barium enema X-ray LABS: CBC WNL. Chemistry revealed dehydration. Abdominal x-ray revealed SBO. UGI WNL. Barium enema revealed mid-transverse colon IS & reduced.
CDC 'Split Type': WAES0710USA03475

Write-up: Information has been received from a physician concerning an 8 month old male with reflux and history of "MSPI type" diet with no other medical history or drug allergies who on 22-MAR-2007, 24-MAY-2007 and 25-JUL-2007 was vaccinated PO with his first, second and third doses (lot# 656381/0875U) of Rotateq. Concomitant vaccinations administered on 25-JUL-2007 included a dose of DTaP, a dose of poliovirus vaccine inactivated (unspecified) and a dose of (Prevnar). Other concomitant drug therapy included nizatidine (AXID) drops for reflux. On 04-OCT-2007 the patient experienced intussusception and was hospitalized. Medical attention was sought through the physician. Labs and abdominal x-rays were performed. A barium enema was also performed to reduce the intussusception. Subsequently, the patient recovered. There was no product quality complaint. Additional information has been requested. 10/26/07 Patient demographics provided by CDC. 10/30/07 Reviewed vax records which confirms RO dose & lot as reported & provides other vax info. VAERS database updated w/same. 11/2/07 Received hospital medical records which reveal patient experienced bilious vomiting x 2 days & 1 episode of bloody stool. Seen by pcp, sent to ER when vomiting persisted. Admitted 10/4-10/5/2007. Noted to have exanthem, lethargy, reduced oral intake & urine output. Progressed well s/p enema reduction & d/c to home. FINAL DX: Intussusception, enema reduced. Records faxed to CDC.


Changed on 8/31/2010

VAERS ID: 294388 Before After
VAERS Form:
Age:0.5
Gender:Male
Location:Nebraska
Vaccinated:2007-07-25
Onset:2007-10-04
Submitted:2007-10-24
Entered:2007-10-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2657AA / 2 UN / UN
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z1069 / 2 UN / UN
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH B58845H / 2 UN / UN
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0875U / 2 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium enema, Barium enema abnormal, Dehydration, Full blood count normal, Haematochezia, Intussusception, Laboratory test abnormal, Lethargy, Rash, Small intestinal obstruction, Vomiting, X-ray with contrast upper gastrointestinal tract, Enema administration, Urine output decreased, Abdominal X-ray, 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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: AXID
Current Illness: Gastrooesophageal reflux; Medical diet
Preexisting Conditions: PMH: viral infection w/fever 1 week prior to admit & rash 3 days prior to admit. Otitis media 2 weeks prior to admit. GERD.
Allergies:
Diagnostic Lab Data: diagnostic laboratory; abdominal X-ray; barium enema X-ray LABS: CBC WNL. Chemistry revealed dehydration. Abdominal x-ray revealed SBO. UGI WNL. Barium enema revealed mid-transverse colon IS & reduced.
CDC 'Split Type': WAES0710USA03475

Write-up: Information has been received from a physician concerning an 8 month old male with reflux and history of "MSPI type" diet with no other medical history or drug allergies who on 22-MAR-2007, 24-MAY-2007 and 25-JUL-2007 was vaccinated PO with his first, second and third doses (lot# 656381/0875U) of Rotateq. Concomitant vaccinations administered on 25-JUL-2007 included a dose of DTaP, a dose of poliovirus vaccine inactivated (unspecified) and a dose of (Prevnar). Other concomitant drug therapy included nizatidine (AXID) drops for reflux. On 04-OCT-2007 the patient experienced intussusception and was hospitalized. Medical attention was sought through the physician. Labs and abdominal x-rays were performed. A barium enema was also performed to reduce the intussusception. Subsequently, the patient recovered. There was no product quality complaint. Additional information has been requested. 10/26/07 Patient demographics provided by CDC. 10/30/07 Reviewed vax records which confirms RO dose & lot as reported & provides other vax info. VAERS database updated w/same. 11/2/07 Received hospital medical records which reveal patient experienced bilious vomiting x 2 days & 1 episode of bloody stool. Seen by pcp, sent to ER when vomiting persisted. Admitted 10/4-10/5/2007. Noted to have exanthem, lethargy, reduced oral intake & urine output. Progressed well s/p enema reduction & d/c to home. FINAL DX: Intussusception, enema reduced. Records faxed to CDC.


Changed on 5/13/2013

VAERS ID: 294388 Before After
VAERS Form:
Age:0.5
Gender:Male
Location:Nebraska
Vaccinated:2007-07-25
Onset:2007-10-04
Submitted:2007-10-24
Entered:2007-10-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2657AA / 2 UN / UN
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z1069 / 2 UN / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B58845H / 2 UN / UN
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0875U / 2 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0875U / 2 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium enema, Barium enema abnormal, Dehydration, Full blood count normal, Haematochezia, Intussusception, Laboratory test abnormal, Lethargy, Rash, Small intestinal obstruction, Vomiting, X-ray with contrast upper gastrointestinal tract, Enema administration, Urine output decreased, Abdominal X-ray, 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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: AXID
Current Illness: Gastrooesophageal reflux; Medical diet
Preexisting Conditions: PMH: viral infection w/fever 1 week prior to admit & rash 3 days prior to admit. Otitis media 2 weeks prior to admit. GERD.
Allergies:
Diagnostic Lab Data: diagnostic laboratory; abdominal X-ray; barium enema X-ray LABS: CBC WNL. Chemistry revealed dehydration. Abdominal x-ray revealed SBO. UGI WNL. Barium enema revealed mid-transverse colon IS & reduced.
CDC 'Split Type': WAES0710USA03475

Write-up: Information has been received from a physician concerning an 8 month old male with reflux and history of "MSPI type" diet with no other medical history or drug allergies who on 22-MAR-2007, 24-MAY-2007 and 25-JUL-2007 was vaccinated PO with his first, second and third doses (lot# 656381/0875U) of Rotateq. Concomitant vaccinations administered on 25-JUL-2007 included a dose of DTaP, a dose of poliovirus vaccine inactivated (unspecified) and a dose of (Prevnar). Other concomitant drug therapy included nizatidine (AXID) drops for reflux. On 04-OCT-2007 the patient experienced intussusception and was hospitalized. Medical attention was sought through the physician. Labs and abdominal x-rays were performed. A barium enema was also performed to reduce the intussusception. Subsequently, the patient recovered. There was no product quality complaint. Additional information has been requested. 10/26/07 Patient demographics provided by CDC. 10/30/07 Reviewed vax records which confirms RO dose & lot as reported & provides other vax info. VAERS database updated w/same. 11/2/07 Received hospital medical records which reveal patient experienced bilious vomiting x 2 days & 1 episode of bloody stool. Seen by pcp, sent to ER when vomiting persisted. Admitted 10/4-10/5/2007. Noted to have exanthem, lethargy, reduced oral intake & urine output. Progressed well s/p enema reduction & d/c to home. FINAL DX: Intussusception, enema reduced. Records faxed to CDC.


Changed on 4/14/2017

VAERS ID: 294388 Before After
VAERS Form:
Age:0.5
Gender:Male
Location:Nebraska
Vaccinated:2007-07-25
Onset:2007-10-04
Submitted:2007-10-24
Entered:2007-10-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2657AA / 2 UN / UN
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z1069 / 2 UN / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B58845H / 2 UN / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0875U / 2 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium enema, Barium enema abnormal, Dehydration, Full blood count normal, Haematochezia, Intussusception, Laboratory test abnormal, Lethargy, Rash, Small intestinal obstruction, Vomiting, X-ray with contrast upper gastrointestinal tract, Enema administration, Urine output decreased, Abdominal X-ray, 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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: AXID
Current Illness: Gastrooesophageal reflux; Medical diet
Preexisting Conditions: PMH: viral infection w/fever 1 week prior to admit & rash 3 days prior to admit. Otitis media 2 weeks prior to admit. GERD.
Allergies:
Diagnostic Lab Data: diagnostic laboratory; abdominal X-ray; barium enema X-ray LABS: CBC WNL. Chemistry revealed dehydration. Abdominal x-ray revealed SBO. UGI WNL. Barium enema revealed mid-transverse colon IS & reduced.
CDC 'Split Type': WAES0710USA03475

Write-up: Information has been received from a physician concerning an 8 month old male with reflux and history of "MSPI type" diet with no other medical history or drug allergies who on 22-MAR-2007, 24-MAY-2007 and 25-JUL-2007 was vaccinated PO with his first, second and third doses (lot# 656381/0875U) of Rotateq. Concomitant vaccinations administered on 25-JUL-2007 included a dose of DTaP, a dose of poliovirus vaccine inactivated (unspecified) and a dose of (Prevnar). Other concomitant drug therapy included nizatidine (AXID) drops for reflux. On 04-OCT-2007 the patient experienced intussusception and was hospitalized. Medical attention was sought through the physician. Labs and abdominal x-rays were performed. A barium enema was also performed to reduce the intussusception. Subsequently, the patient recovered. There was no product quality complaint. Additional information has been requested. 10/26/07 Patient demographics provided by CDC. 10/30/07 Reviewed vax records which confirms RO dose & lot as reported & provides other vax info. VAERS database updated w/same. 11/2/07 Received hospital medical records which reveal patient experienced bilious vomiting x 2 days & 1 episode of bloody stool. Seen by pcp, sent to ER when vomiting persisted. Admitted 10/4-10/5/2007. Noted to have exanthem, lethargy, reduced oral intake & urine output. Progressed well s/p enema reduction & d/c to home. FINAL DX: Intussusception, enema reduced. Records faxed to CDC.


Changed on 9/14/2017

VAERS ID: 294388 Before After
VAERS Form:(blank) 1
Age:0.5
Gender:Male
Location:Nebraska
Vaccinated:2007-07-25
Onset:2007-10-04
Submitted:2007-10-24
Entered:2007-10-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2657AA / 2 3 UN / UN
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z1069 / 2 3 UN / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B58845H / 2 3 UN / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0875U / 2 3 - MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium enema, Intussusception, Abdominal X-ray

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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: AXID
Current Illness: Gastrooesophageal reflux; Medical diet
Preexisting Conditions: PMH: viral infection w/fever 1 week prior to admit & rash 3 days prior to admit. Otitis media 2 weeks prior to admit. GERD.
Allergies:
Diagnostic Lab Data: diagnostic laboratory; abdominal X-ray; barium enema X-ray LABS: CBC WNL. Chemistry revealed dehydration. Abdominal x-ray revealed SBO. UGI WNL. Barium enema revealed mid-transverse colon IS & reduced.
CDC 'Split Type': WAES0710USA03475

Write-up: Information has been received from a physician concerning an 8 month old male with reflux and history of "MSPI type" diet with no other medical history or drug allergies who on 22-MAR-2007, 24-MAY-2007 and 25-JUL-2007 was vaccinated PO with his first, second and third doses (lot# 656381/0875U) of Rotateq. Concomitant vaccinations administered on 25-JUL-2007 included a dose of DTaP, a dose of poliovirus vaccine inactivated (unspecified) and a dose of (Prevnar). Other concomitant drug therapy included nizatidine (AXID) drops for reflux. On 04-OCT-2007 the patient experienced intussusception and was hospitalized. Medical attention was sought through the physician. Labs and abdominal x-rays were performed. A barium enema was also performed to reduce the intussusception. Subsequently, the patient recovered. There was no product quality complaint. Additional information has been requested. 10/26/07 Patient demographics provided by CDC. 10/30/07 Reviewed vax records which confirms RO dose & lot as reported & provides other vax info. VAERS database updated w/same. 11/2/07 Received hospital medical records which reveal patient experienced bilious vomiting x 2 days & 1 episode of bloody stool. Seen by pcp, sent to ER when vomiting persisted. Admitted 10/4-10/5/2007. Noted to have exanthem, lethargy, reduced oral intake & urine output. Progressed well s/p enema reduction & d/c to home. FINAL DX: Intussusception, enema reduced. Records faxed to CDC.


Changed on 2/14/2018

VAERS ID: 294388 Before After
VAERS Form:1
Age:0.5
Gender:Male
Location:Nebraska
Vaccinated:2007-07-25
Onset:2007-10-04
Submitted:2007-10-24
Entered:2007-10-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2657AA / 3 UN / UN
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z1069 / 3 UN / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B58845H / 3 UN / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0875U / 3 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium enema, Intussusception, Abdominal X-ray

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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: AXID
Current Illness: Gastrooesophageal reflux; Medical diet
Preexisting Conditions: PMH: viral infection w/fever 1 week prior to admit & rash 3 days prior to admit. Otitis media 2 weeks prior to admit. GERD.
Allergies:
Diagnostic Lab Data: diagnostic laboratory; abdominal X-ray; barium enema X-ray LABS: CBC WNL. Chemistry revealed dehydration. Abdominal x-ray revealed SBO. UGI WNL. Barium enema revealed mid-transverse colon IS & reduced.
CDC 'Split Type': WAES0710USA03475

Write-up: Information has been received from a physician concerning an 8 month old male with reflux and history of "MSPI type" diet with no other medical history or drug allergies who on 22-MAR-2007, 24-MAY-2007 and 25-JUL-2007 was vaccinated PO with his first, second and third doses (lot# 656381/0875U) of Rotateq. Concomitant vaccinations administered on 25-JUL-2007 included a dose of DTaP, a dose of poliovirus vaccine inactivated (unspecified) and a dose of (Prevnar). Other concomitant drug therapy included nizatidine (AXID) drops for reflux. On 04-OCT-2007 the patient experienced intussusception and was hospitalized. Medical attention was sought through the physician. Labs and abdominal x-rays were performed. A barium enema was also performed to reduce the intussusception. Subsequently, the patient recovered. There was no product quality complaint. Additional information has been requested. 10/26/07 Patient demographics provided by CDC. 10/30/07 Reviewed vax records which confirms RO dose & lot as reported & provides other vax info. VAERS database updated w/same. 11/2/07 Received hospital medical records which reveal patient experienced bilious vomiting x 2 days & 1 episode of bloody stool. Seen by pcp, sent to ER when vomiting persisted. Admitted 10/4-10/5/2007. Noted to have exanthem, lethargy, reduced oral intake & urine output. Progressed well s/p enema reduction & d/c to home. FINAL DX: Intussusception, enema reduced. Records faxed to CDC.


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