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This is VAERS ID 294705

Case Details

VAERS ID: 294705 (history)  
Form: Version 1.0  
Age: 0.18  
Gender: Male  
Location: California  
Vaccinated:2007-09-11
Onset:2007-10-24
   Days after vaccination:43
Submitted: 2007-10-29
   Days after onset:5
Entered: 2007-10-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B090AA / 1 UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0079U / 1 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B474420 / 1 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1167F / 1 MO / PO

Administered by: Other       Purchased by: Public
Symptoms: Intussusception
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: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Xray tests LABS: abdominal x-ray & US c/w ileocolic IS. Air reduction enema successfully reduced IS.
CDC Split Type:

Write-up: Hospitalized with intussusception on 10/24/07. 12/4/07 Reviewed vax record which confirms dose & lot numbers as reported. Records faxed to CDC. 12/7/07 Reviewed hospital medical records which reveal patient experienced vomiting & bloody stool. Had been seen at outlying ER & transferred to higher level of care. Admitted 10/24/2007 & d/c to home same day. FINAL DX: Intussusception, enema reduced. Records faxed to CDC.


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