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This is VAERS ID 295526

History of Changes from the VAERS Wayback Machine

First Appeared on 12/31/2007

295526
VAERS Form:
Age:11.0
Gender:Female
Location:California
Vaccinated:2007-10-19
Onset:2007-10-27
Submitted:2007-11-05
Entered:2007-11-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (FLUZONE) / SANOFI PASTEUR U2435AA / - LA / -
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 0012U / 0 LA / -
MNQ: MENINGOCOCCAL (MENACTRA) / SANOFI PASTEUR U2208AA / 0 LA / -
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS AC52B013AA / 5 LA / -
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 0127U / 1 LA / -

Administered by: Unknown      Purchased by: Unknown
Symptoms: Ataxia, Blood culture negative, C-reactive protein increased, CSF culture negative, CSF lymphocyte count increased

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit? (V2.0) No
Hospitalized? Yes, days: 8     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: LABS: CT scan WNL. MRI initially WNL. Repeat MRI revealed focal lesion in corpus callosum. MRA of neck WNL. CSF protein 118 (H), WBC 54 (H), RBC 2 (H), lymphs 92% (H), monos 8% (L). HSCRP 2.05 (H)Blood, urine & CSF cultures neg. Trach
CDC 'Split Type':

Write-up:approximately 2 weeks after vaccine administration developed headache, ataxia, and seizures requiring antiepileptics, steroids, antibiotics


Changed on 12/8/2009

295526 Before After
VAERS Form:
Age:11.0
Gender:Female
Location:California
Vaccinated:2007-10-19
Onset:2007-10-27
Submitted:2007-11-05
Entered:2007-11-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (FLUZONE) INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U2435AA / - LA / -
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 0012U / 0 LA / -
MNQ: MENINGOCOCCAL (MENACTRA) / SANOFI PASTEUR U2208AA / 0 LA / -
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS AC52B013AA / 5 LA / -
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 0127U / 1 LA / -

Administered by: Unknown      Purchased by: Unknown
Symptoms: Ataxia, Blood culture negative, C-reactive protein increased, Computerised tomogram normal, Convulsion, Cough, CSF culture negative, CSF lymphocyte count increased, CSF protein increased, Culture throat positive, Culture urine negative, Dizziness, Encephalitis, Headache, Intensive care, Lumbar puncture, Muscle spasticity, Nervous system disorder, Nuclear magnetic resonance imaging brain abnormal, Pyrexia, Red blood cells CSF positive, Viral infection, Vomiting, CSF monocyte count decreased, CSF white blood cell count increased, Staphylococcal infection, Mechanical ventilation

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit? (V2.0) No
Hospitalized? Yes, days: 8     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: LABS: CT scan WNL. MRI initially WNL. Repeat MRI revealed focal lesion in corpus callosum. MRA of neck WNL. CSF protein 118 (H), WBC 54 (H), RBC 2 (H), lymphs 92% (H), monos 8% (L). HSCRP 2.05 (H)Blood, urine & CSF cultures neg. Trach
CDC 'Split Type':

Write-up:approximately 2 weeks after vaccine administration developed headache, ataxia, and seizures requiring antiepileptics, steroids, antibiotics. 11/6/07 Received vax records & pcp medical records. VAERS database updated w/same & date of vax corrected to 10/19/2007. Flu shot not on vax record but ordered on pcp note. Pcp note of 10/19 indicates patient in good health on day of vax. Returned to pcp 11/2/07 w/dizziness, fever, HA, slight cough. Dx w/viral infection. T/C to provider to clarify vax info. Received 2nd page of vax record w/flu vax info. VAERS database updated w/same. 11/30/07 Reviewed hospital medical records which reveal patient experienced HA, vomiting, ataxia & right sided spasticity. Had HA x 7 days prior to admitl w/increasing ataxia x 3 days. Admitted 11/2-11/10/2007. As preparing for LP, patient had seizure & desaturation. Intubated & admitted to PICU. Neuro consult done. Given IV antibiotics & antivirals until cultures came back neg. Extubated 11/5 & progressed well on antiseizure meds. FINAL DX: Encephalitis; ataxia; headache.


Changed on 4/7/2010

295526 Before After
VAERS Form:
Age:11.0
Gender:Female
Location:California
Vaccinated:2007-10-19
Onset:2007-10-27
Submitted:2007-11-05
Entered:2007-11-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U2435AA / - LA / -
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 0012U / 0 LA / -
MNQ: MENINGOCOCCAL (MENACTRA) MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U2208AA / 0 LA / -
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS AC52B013AA / 5 LA / -
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 0127U / 1 LA / -

Administered by: Unknown      Purchased by: Unknown
Symptoms: Ataxia, Blood culture negative, C-reactive protein increased, Computerised tomogram normal, Convulsion, Cough, CSF culture negative, CSF lymphocyte count increased, CSF protein increased, Culture throat positive, Culture urine negative, Dizziness, Encephalitis, Headache, Intensive care, Lumbar puncture, Muscle spasticity, Nervous system disorder, Nuclear magnetic resonance imaging brain abnormal, Pyrexia, Red blood cells CSF positive, Viral infection, Vomiting, CSF monocyte count decreased, CSF white blood cell count increased, Staphylococcal infection, Mechanical ventilation

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit? (V2.0) No
Hospitalized? Yes, days: 8     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: LABS: CT scan WNL. MRI initially WNL. Repeat MRI revealed focal lesion in corpus callosum. MRA of neck WNL. CSF protein 118 (H), WBC 54 (H), RBC 2 (H), lymphs 92% (H), monos 8% (L). HSCRP 2.05 (H)Blood, urine & CSF cultures neg. Trach
CDC 'Split Type':

Write-up:approximately 2 weeks after vaccine administration developed headache, ataxia, and seizures requiring antiepileptics, steroids, antibiotics. 11/6/07 Received vax records & pcp medical records. VAERS database updated w/same & date of vax corrected to 10/19/2007. Flu shot not on vax record but ordered on pcp note. Pcp note of 10/19 indicates patient in good health on day of vax. Returned to pcp 11/2/07 w/dizziness, fever, HA, slight cough. Dx w/viral infection. T/C to provider to clarify vax info. Received 2nd page of vax record w/flu vax info. VAERS database updated w/same. 11/30/07 Reviewed hospital medical records which reveal patient experienced HA, vomiting, ataxia & right sided spasticity. Had HA x 7 days prior to admitl w/increasing ataxia x 3 days. Admitted 11/2-11/10/2007. As preparing for LP, patient had seizure & desaturation. Intubated & admitted to PICU. Neuro consult done. Given IV antibiotics & antivirals until cultures came back neg. Extubated 11/5 & progressed well on antiseizure meds. FINAL DX: Encephalitis; ataxia; headache.


Changed on 7/7/2013

295526 Before After
VAERS Form:
Age:11.0
Gender:Female
Location:California
Vaccinated:2007-10-19
Onset:2007-10-27
Submitted:2007-11-05
Entered:2007-11-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U2435AA / - LA / -
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U2435AA / - LA / -
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 0012U / 0 LA / -
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U2208AA / 0 LA / -
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS AC52B013AA / 5 LA / -
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 0127U / 1 LA / -

Administered by: Unknown      Purchased by: Unknown
Symptoms: Ataxia, Blood culture negative, C-reactive protein increased, Computerised tomogram normal, Convulsion, Cough, CSF culture negative, CSF lymphocyte count increased, CSF protein increased, Culture throat positive, Culture urine negative, Dizziness, Encephalitis, Headache, Intensive care, Lumbar puncture, Muscle spasticity, Nervous system disorder, Nuclear magnetic resonance imaging brain abnormal, Pyrexia, Red blood cells CSF positive, Viral infection, Vomiting, CSF monocyte count decreased, CSF white blood cell count increased, Staphylococcal infection, Mechanical ventilation

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit? (V2.0) No
Hospitalized? Yes, days: 8     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: LABS: CT scan WNL. MRI initially WNL. Repeat MRI revealed focal lesion in corpus callosum. MRA of neck WNL. CSF protein 118 (H), WBC 54 (H), RBC 2 (H), lymphs 92% (H), monos 8% (L). HSCRP 2.05 (H)Blood, urine & CSF cultures neg. Trach
CDC 'Split Type':

Write-up:approximately 2 weeks after vaccine administration developed headache, ataxia, and seizures requiring antiepileptics, steroids, antibiotics. 11/6/07 Received vax records & pcp medical records. VAERS database updated w/same & date of vax corrected to 10/19/2007. Flu shot not on vax record but ordered on pcp note. Pcp note of 10/19 indicates patient in good health on day of vax. Returned to pcp 11/2/07 w/dizziness, fever, HA, slight cough. Dx w/viral infection. T/C to provider to clarify vax info. Received 2nd page of vax record w/flu vax info. VAERS database updated w/same. 11/30/07 Reviewed hospital medical records which reveal patient experienced HA, vomiting, ataxia & right sided spasticity. Had HA x 7 days prior to admitl w/increasing ataxia x 3 days. Admitted 11/2-11/10/2007. As preparing for LP, patient had seizure & desaturation. Intubated & admitted to PICU. Neuro consult done. Given IV antibiotics & antivirals until cultures came back neg. Extubated 11/5 & progressed well on antiseizure meds. FINAL DX: Encephalitis; ataxia; headache.


Changed on 4/14/2017

295526 Before After
VAERS Form:
Age:11.0
Gender:Female
Location:California
Vaccinated:2007-10-19
Onset:2007-10-27
Submitted:2007-11-05
Entered:2007-11-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U2435AA / - LA / -
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 0012U / 0 LA / -
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U2208AA / 0 LA / -
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS AC52B013AA / 5 LA / -
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 0127U / 1 LA / -

Administered by: Unknown      Purchased by: Unknown
Symptoms: Ataxia, Blood culture negative, C-reactive protein increased, Computerised tomogram normal, Convulsion, Cough, CSF culture negative, CSF lymphocyte count increased, CSF protein increased, Culture throat positive, Culture urine negative, Dizziness, Encephalitis, Headache, Intensive care, Lumbar puncture, Muscle spasticity, Nervous system disorder, Nuclear magnetic resonance imaging brain abnormal, Pyrexia, Red blood cells CSF positive, Viral infection, Vomiting, CSF monocyte count decreased, CSF white blood cell count increased, Staphylococcal infection, Mechanical ventilation

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit? (V2.0) No
Hospitalized? Yes, days: 8     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: LABS: CT scan WNL. MRI initially WNL. Repeat MRI revealed focal lesion in corpus callosum. MRA of neck WNL. CSF protein 118 (H), WBC 54 (H), RBC 2 (H), lymphs 92% (H), monos 8% (L). HSCRP 2.05 (H)Blood, urine & CSF cultures neg. Trach aspirate culture (+) staph aureus (not MRSA).
CDC 'Split Type':

Write-up:approximately 2 weeks after vaccine administration developed headache, ataxia, and seizures requiring antiepileptics, steroids, antibiotics. 11/6/07 Received vax records & pcp medical records. VAERS database updated w/same & date of vax corrected to 10/19/2007. Flu shot not on vax record but ordered on pcp note. Pcp note of 10/19 indicates patient in good health on day of vax. Returned to pcp 11/2/07 w/dizziness, fever, HA, slight cough. Dx w/viral infection. T/C to provider to clarify vax info. Received 2nd page of vax record w/flu vax info. VAERS database updated w/same. 11/30/07 Reviewed hospital medical records which reveal patient experienced HA, vomiting, ataxia & right sided spasticity. Had HA x 7 days prior to admitl w/increasing ataxia x 3 days. Admitted 11/2-11/10/2007. As preparing for LP, patient had seizure & desaturation. Intubated & admitted to PICU. Neuro consult done. Given IV antibiotics & antivirals until cultures came back neg. Extubated 11/5 & progressed well on antiseizure meds. FINAL DX: Encephalitis; ataxia; headache.


Changed on 9/14/2017

295526 Before After
VAERS Form:(blank) 1
Age:11.0
Gender:Female
Location:California
Vaccinated:2007-10-19
Onset:2007-10-27
Submitted:2007-11-05
Entered:2007-11-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U2435AA / - UNK LA / -
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 0012U / 0 1 LA / -
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U2208AA / 0 1 LA / -
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS AC52B013AA / 5 6 LA / -
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 0127U / 1 2 LA / -

Administered by: Unknown      Purchased by: Unknown
Symptoms: Ataxia, Convulsion, Headache

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit? (V2.0) No
Hospitalized? Yes, days: 8     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: LABS: CT scan WNL. MRI initially WNL. Repeat MRI revealed focal lesion in corpus callosum. MRA of neck WNL. CSF protein 118 (H), WBC 54 (H), RBC 2 (H), lymphs 92% (H), monos 8% (L). HSCRP 2.05 (H)Blood, urine & CSF cultures neg. Trach aspirate culture (+) staph aureus (not MRSA).
CDC 'Split Type':

Write-up:approximately 2 weeks after vaccine administration developed headache, ataxia, and seizures requiring antiepileptics, steroids, antibiotics. 11/6/07 Received vax records & pcp medical records. VAERS database updated w/same & date of vax corrected to 10/19/2007. Flu shot not on vax record but ordered on pcp note. Pcp note of 10/19 indicates patient in good health on day of vax. Returned to pcp 11/2/07 w/dizziness, fever, HA, slight cough. Dx w/viral infection. T/C to provider to clarify vax info. Received 2nd page of vax record w/flu vax info. VAERS database updated w/same. 11/30/07 Reviewed hospital medical records which reveal patient experienced HA, vomiting, ataxia & right sided spasticity. Had HA x 7 days prior to admitl w/increasing ataxia x 3 days. Admitted 11/2-11/10/2007. As preparing for LP, patient had seizure & desaturation. Intubated & admitted to PICU. Neuro consult done. Given IV antibiotics & antivirals until cultures came back neg. Extubated 11/5 & progressed well on antiseizure meds. FINAL DX: Encephalitis; ataxia; headache.


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