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This is VAERS ID 298456

History of Changes from the VAERS Wayback Machine

First Appeared on 12/31/2007

VAERS ID: 298456
VAERS Form:
Age:0.4
Gender:Female
Location:California
Vaccinated:2007-11-09
Onset:2007-11-20
Submitted:2007-11-30
Entered:2007-12-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124BA / 1 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0255U / 1 RL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B70143K / 1 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0669U / 1 - / PO

Administered by: Other      Purchased by: Unknown
Symptoms: Abdominal distension, Abdominal mass, Abnormal faeces, Barium enema, Enema administration

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: antimicrobial (unspecified)
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: barium enema X-ray 11/??/07
CDC 'Split Type':

Write-up: Information has been received from a physician concerning a 4 month old female who on approximately 06-NOV-2007 was vaccinated PO with the second 2.0 ml dose of Rotateq (no lot number provided). Concomitant drug therapy included /"antimicrobial (unspecifi"ed)./" On 20-NOV-2007 two and a half weeks after being vaccinated, the patient experienced intussusception characterized by an abnormal stool and was hospitalized for a total of 3 days. A barium enema test was performed and the patient underwent surgery t


Changed on 12/8/2009

VAERS ID: 298456 Before After
VAERS Form:
Age:0.4
Gender:Female
Location:California
Vaccinated:2007-11-09
Onset:2007-11-20
Submitted:2007-11-30
Entered:2007-12-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124BA / 1 LL / IM
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124BA / 1 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0255U / 1 RL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B70143K / 1 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0669U / 1 - / PO

Administered by: Other      Purchased by: Unknown Other
Symptoms: Abdominal distension, Abdominal mass, Abnormal faeces, Barium enema, Faeces discoloured, Gastrointestinal necrosis, Haematochezia, Intestinal ulcer, Intussusception, Irritability, Lethargy, Purulent discharge, Surgery, Vomiting, Enema administration, Explorative laparotomy, Haemorrhage, Appendix disorder, Inflammation, Virus serology test, Rotavirus test negative

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: antimicrobial (unspecified)
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: barium enema X-ray 11/??/07 4/15/08 Received additional lab reports from CDC: appendix revealed extensive ulcerated mucosa w/necrosis & fibromucopurulent debris in lumen, mixed inflammatory cell infiltrates & hemorrhage. Testing for ade
CDC 'Split Type': (blank) WAES0711USA04977

Write-up: Information has been received from a physician concerning a 4 month old female who on approximately 06-NOV-2007 was vaccinated PO with the second 2.0 ml dose of Rotateq (no lot number provided). Concomitant drug therapy included /"antimicrobial (unspecifi"ed)./" "antimicrobial (unspecified)." On 20-NOV-2007 two and a half weeks after being vaccinated, the patient experienced intussusception characterized by an abnormal stool and was hospitalized for a total of 3 days. A barium enema test was performed and the patient underwent surgery t to repair the intussusception." On 23-NOV-2007 the patient was released from the hospital. Subsequently, the patient recovered. There was no product quality complaint. The physician also considered intussusception to be an other important medical event (surgery). Additional information has been requested. 1/11/08 Reviewed hospital medical records which reveal patient experienced irritability, black stools & bilious emesis x 12 hours which progressed to bloody stools. Went to outlying ER where gastrograffin enema reveals IS that could not be reduced despite 3 attemps. Transferred to higher level of care for surgical management. Admitted 11/20-11/23/2007. On admit, lethargic, distended abdomen w/epigastric mass palpablel. To OR for exp lap, no bowel resection needed. Did well post op & d/c to home. Final DX: intussusception, surgically reduced. 1/22/08 Reviewed vax record.


Changed on 3/2/2010

VAERS ID: 298456 Before After
VAERS Form:
Age:0.4
Gender:Female
Location:California
Vaccinated:2007-11-09
Onset:2007-11-20
Submitted:2007-11-30
Entered:2007-12-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124BA / 1 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0255U / 1 RL / IM
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC B70143K / 1 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0669U / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal distension, Abdominal mass, Abnormal faeces, Barium enema, Faeces discoloured, Gastrointestinal necrosis, Haematochezia, Intestinal ulcer, Intussusception, Irritability, Lethargy, Purulent discharge, Surgery, Vomiting, Enema administration, Explorative laparotomy, Haemorrhage, Appendix disorder, Inflammation, Virus serology test, Rotavirus test negative

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: antimicrobial (unspecified)
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: barium enema X-ray 11/??/07 4/15/08 Received additional lab reports from CDC: appendix revealed extensive ulcerated mucosa w/necrosis & fibromucopurulent debris in lumen, mixed inflammatory cell infiltrates & hemorrhage. Testing for ade
CDC 'Split Type': WAES0711USA04977

Write-up: Information has been received from a physician concerning a 4 month old female who on approximately 06-NOV-2007 was vaccinated PO with the second 2.0 ml dose of Rotateq (no lot number provided). Concomitant drug therapy included "antimicrobial (unspecified)." On 20-NOV-2007 two and a half weeks after being vaccinated, the patient experienced intussusception characterized by an abnormal stool and was hospitalized for a total of 3 days. A barium enema test was performed and the patient underwent surgery to repair the intussusception." On 23-NOV-2007 the patient was released from the hospital. Subsequently, the patient recovered. There was no product quality complaint. The physician also considered intussusception to be an other important medical event (surgery). Additional information has been requested. 1/11/08 Reviewed hospital medical records which reveal patient experienced irritability, black stools & bilious emesis x 12 hours which progressed to bloody stools. Went to outlying ER where gastrograffin enema reveals IS that could not be reduced despite 3 attemps. Transferred to higher level of care for surgical management. Admitted 11/20-11/23/2007. On admit, lethargic, distended abdomen w/epigastric mass palpablel. To OR for exp lap, no bowel resection needed. Did well post op & d/c to home. Final DX: intussusception, surgically reduced. 1/22/08 Reviewed vax record.


Changed on 4/7/2010

VAERS ID: 298456 Before After
VAERS Form:
Age:0.4
Gender:Female
Location:California
Vaccinated:2007-11-09
Onset:2007-11-20
Submitted:2007-11-30
Entered:2007-12-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124BA / 1 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0255U / 1 RL / IM
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B70143K / 1 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0669U / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal distension, Abdominal mass, Abnormal faeces, Barium enema, Faeces discoloured, Gastrointestinal necrosis, Haematochezia, Intestinal ulcer, Intussusception, Irritability, Lethargy, Purulent discharge, Surgery, Vomiting, Enema administration, Explorative laparotomy, Haemorrhage, Appendix disorder, Inflammation, Virus serology test, Rotavirus test negative

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: antimicrobial (unspecified)
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: barium enema X-ray 11/??/07 4/15/08 Received additional lab reports from CDC: appendix revealed extensive ulcerated mucosa w/necrosis & fibromucopurulent debris in lumen, mixed inflammatory cell infiltrates & hemorrhage. Testing for ade
CDC 'Split Type': WAES0711USA04977

Write-up: Information has been received from a physician concerning a 4 month old female who on approximately 06-NOV-2007 was vaccinated PO with the second 2.0 ml dose of Rotateq (no lot number provided). Concomitant drug therapy included "antimicrobial (unspecified)." On 20-NOV-2007 two and a half weeks after being vaccinated, the patient experienced intussusception characterized by an abnormal stool and was hospitalized for a total of 3 days. A barium enema test was performed and the patient underwent surgery to repair the intussusception." On 23-NOV-2007 the patient was released from the hospital. Subsequently, the patient recovered. There was no product quality complaint. The physician also considered intussusception to be an other important medical event (surgery). Additional information has been requested. 1/11/08 Reviewed hospital medical records which reveal patient experienced irritability, black stools & bilious emesis x 12 hours which progressed to bloody stools. Went to outlying ER where gastrograffin enema reveals IS that could not be reduced despite 3 attemps. Transferred to higher level of care for surgical management. Admitted 11/20-11/23/2007. On admit, lethargic, distended abdomen w/epigastric mass palpablel. To OR for exp lap, no bowel resection needed. Did well post op & d/c to home. Final DX: intussusception, surgically reduced. 1/22/08 Reviewed vax record.


Changed on 8/31/2010

VAERS ID: 298456 Before After
VAERS Form:
Age:0.4
Gender:Female
Location:California
Vaccinated:2007-11-09
Onset:2007-11-20
Submitted:2007-11-30
Entered:2007-12-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124BA / 1 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0255U / 1 RL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH B70143K / 1 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0669U / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal distension, Abdominal mass, Abnormal faeces, Barium enema, Faeces discoloured, Gastrointestinal necrosis, Haematochezia, Intestinal ulcer, Intussusception, Irritability, Lethargy, Purulent discharge, Surgery, Vomiting, Enema administration, Explorative laparotomy, Haemorrhage, Appendix disorder, Inflammation, Virus serology test, Rotavirus test negative

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: antimicrobial (unspecified)
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: barium enema X-ray 11/??/07 4/15/08 Received additional lab reports from CDC: appendix revealed extensive ulcerated mucosa w/necrosis & fibromucopurulent debris in lumen, mixed inflammatory cell infiltrates & hemorrhage. Testing for ade
CDC 'Split Type': WAES0711USA04977

Write-up: Information has been received from a physician concerning a 4 month old female who on approximately 06-NOV-2007 was vaccinated PO with the second 2.0 ml dose of Rotateq (no lot number provided). Concomitant drug therapy included "antimicrobial (unspecified)." On 20-NOV-2007 two and a half weeks after being vaccinated, the patient experienced intussusception characterized by an abnormal stool and was hospitalized for a total of 3 days. A barium enema test was performed and the patient underwent surgery to repair the intussusception." On 23-NOV-2007 the patient was released from the hospital. Subsequently, the patient recovered. There was no product quality complaint. The physician also considered intussusception to be an other important medical event (surgery). Additional information has been requested. 1/11/08 Reviewed hospital medical records which reveal patient experienced irritability, black stools & bilious emesis x 12 hours which progressed to bloody stools. Went to outlying ER where gastrograffin enema reveals IS that could not be reduced despite 3 attemps. Transferred to higher level of care for surgical management. Admitted 11/20-11/23/2007. On admit, lethargic, distended abdomen w/epigastric mass palpablel. To OR for exp lap, no bowel resection needed. Did well post op & d/c to home. Final DX: intussusception, surgically reduced. 1/22/08 Reviewed vax record.


Changed on 5/13/2013

VAERS ID: 298456 Before After
VAERS Form:
Age:0.4
Gender:Female
Location:California
Vaccinated:2007-11-09
Onset:2007-11-20
Submitted:2007-11-30
Entered:2007-12-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124BA / 1 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0255U / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B70143K / 1 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0669U / 1 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0669U / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal distension, Abdominal mass, Abnormal faeces, Barium enema, Faeces discoloured, Gastrointestinal necrosis, Haematochezia, Intestinal ulcer, Intussusception, Irritability, Lethargy, Purulent discharge, Surgery, Vomiting, Enema administration, Explorative laparotomy, Haemorrhage, Appendix disorder, Inflammation, Virus serology test, Rotavirus test negative

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: antimicrobial (unspecified)
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: barium enema X-ray 11/??/07 4/15/08 Received additional lab reports from CDC: appendix revealed extensive ulcerated mucosa w/necrosis & fibromucopurulent debris in lumen, mixed inflammatory cell infiltrates & hemorrhage. Testing for ade
CDC 'Split Type': WAES0711USA04977

Write-up: Information has been received from a physician concerning a 4 month old female who on approximately 06-NOV-2007 was vaccinated PO with the second 2.0 ml dose of Rotateq (no lot number provided). Concomitant drug therapy included "antimicrobial (unspecified)." On 20-NOV-2007 two and a half weeks after being vaccinated, the patient experienced intussusception characterized by an abnormal stool and was hospitalized for a total of 3 days. A barium enema test was performed and the patient underwent surgery to repair the intussusception." On 23-NOV-2007 the patient was released from the hospital. Subsequently, the patient recovered. There was no product quality complaint. The physician also considered intussusception to be an other important medical event (surgery). Additional information has been requested. 1/11/08 Reviewed hospital medical records which reveal patient experienced irritability, black stools & bilious emesis x 12 hours which progressed to bloody stools. Went to outlying ER where gastrograffin enema reveals IS that could not be reduced despite 3 attemps. Transferred to higher level of care for surgical management. Admitted 11/20-11/23/2007. On admit, lethargic, distended abdomen w/epigastric mass palpablel. To OR for exp lap, no bowel resection needed. Did well post op & d/c to home. Final DX: intussusception, surgically reduced. 1/22/08 Reviewed vax record.


Changed on 4/14/2017

VAERS ID: 298456 Before After
VAERS Form:
Age:0.4
Gender:Female
Location:California
Vaccinated:2007-11-09
Onset:2007-11-20
Submitted:2007-11-30
Entered:2007-12-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124BA / 1 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0255U / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B70143K / 1 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0669U / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal distension, Abdominal mass, Abnormal faeces, Barium enema, Faeces discoloured, Gastrointestinal necrosis, Haematochezia, Intestinal ulcer, Intussusception, Irritability, Lethargy, Purulent discharge, Surgery, Vomiting, Enema administration, Explorative laparotomy, Haemorrhage, Appendix disorder, Inflammation, Virus serology test, Rotavirus test negative

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: antimicrobial (unspecified)
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: barium enema X-ray 11/??/07 4/15/08 Received additional lab reports from CDC: appendix revealed extensive ulcerated mucosa w/necrosis & fibromucopurulent debris in lumen, mixed inflammatory cell infiltrates & hemorrhage. Testing for ade adenovirus & rotavirus were neg.
CDC 'Split Type': WAES0711USA04977

Write-up: Information has been received from a physician concerning a 4 month old female who on approximately 06-NOV-2007 was vaccinated PO with the second 2.0 ml dose of Rotateq (no lot number provided). Concomitant drug therapy included "antimicrobial (unspecified)." On 20-NOV-2007 two and a half weeks after being vaccinated, the patient experienced intussusception characterized by an abnormal stool and was hospitalized for a total of 3 days. A barium enema test was performed and the patient underwent surgery to repair the intussusception." On 23-NOV-2007 the patient was released from the hospital. Subsequently, the patient recovered. There was no product quality complaint. The physician also considered intussusception to be an other important medical event (surgery). Additional information has been requested. 1/11/08 Reviewed hospital medical records which reveal patient experienced irritability, black stools & bilious emesis x 12 hours which progressed to bloody stools. Went to outlying ER where gastrograffin enema reveals IS that could not be reduced despite 3 attemps. Transferred to higher level of care for surgical management. Admitted 11/20-11/23/2007. On admit, lethargic, distended abdomen w/epigastric mass palpablel. To OR for exp lap, no bowel resection needed. Did well post op & d/c to home. Final DX: intussusception, surgically reduced. 1/22/08 Reviewed vax record.


Changed on 9/14/2017

VAERS ID: 298456 Before After
VAERS Form:(blank) 1
Age:0.4
Gender:Female
Location:California
Vaccinated:2007-11-09
Onset:2007-11-20
Submitted:2007-11-30
Entered:2007-12-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124BA / 1 2 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0255U / 1 2 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B70143K / 1 2 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0669U / 1 2 - MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Abnormal faeces, Barium enema, Intussusception, Surgery

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: antimicrobial (unspecified)
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: barium enema X-ray 11/??/07 4/15/08 Received additional lab reports from CDC: appendix revealed extensive ulcerated mucosa w/necrosis & fibromucopurulent debris in lumen, mixed inflammatory cell infiltrates & hemorrhage. Testing for adenovirus & rotavirus were neg.
CDC 'Split Type': WAES0711USA04977

Write-up: Information has been received from a physician concerning a 4 month old female who on approximately 06-NOV-2007 was vaccinated PO with the second 2.0 ml dose of Rotateq (no lot number provided). Concomitant drug therapy included "antimicrobial (unspecified)." On 20-NOV-2007 two and a half weeks after being vaccinated, the patient experienced intussusception characterized by an abnormal stool and was hospitalized for a total of 3 days. A barium enema test was performed and the patient underwent surgery to repair the intussusception." On 23-NOV-2007 the patient was released from the hospital. Subsequently, the patient recovered. There was no product quality complaint. The physician also considered intussusception to be an other important medical event (surgery). Additional information has been requested. 1/11/08 Reviewed hospital medical records which reveal patient experienced irritability, black stools & bilious emesis x 12 hours which progressed to bloody stools. Went to outlying ER where gastrograffin enema reveals IS that could not be reduced despite 3 attemps. Transferred to higher level of care for surgical management. Admitted 11/20-11/23/2007. On admit, lethargic, distended abdomen w/epigastric mass palpablel. To OR for exp lap, no bowel resection needed. Did well post op & d/c to home. Final DX: intussusception, surgically reduced. 1/22/08 Reviewed vax record.


Changed on 2/14/2018

VAERS ID: 298456 Before After
VAERS Form:1
Age:0.4
Gender:Female
Location:California
Vaccinated:2007-11-09
Onset:2007-11-20
Submitted:2007-11-30
Entered:2007-12-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124BA / 2 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0255U / 2 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B70143K / 2 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0669U / 2 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Abnormal faeces, Barium enema, Intussusception, Surgery

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: antimicrobial (unspecified)
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: barium enema X-ray 11/??/07 4/15/08 Received additional lab reports from CDC: appendix revealed extensive ulcerated mucosa w/necrosis & fibromucopurulent debris in lumen, mixed inflammatory cell infiltrates & hemorrhage. Testing for adenovirus & rotavirus were neg.
CDC 'Split Type': WAES0711USA04977

Write-up: Information has been received from a physician concerning a 4 month old female who on approximately 06-NOV-2007 was vaccinated PO with the second 2.0 ml dose of Rotateq (no lot number provided). Concomitant drug therapy included "antimicrobial (unspecified)." On 20-NOV-2007 two and a half weeks after being vaccinated, the patient experienced intussusception characterized by an abnormal stool and was hospitalized for a total of 3 days. A barium enema test was performed and the patient underwent surgery to repair the intussusception." On 23-NOV-2007 the patient was released from the hospital. Subsequently, the patient recovered. There was no product quality complaint. The physician also considered intussusception to be an other important medical event (surgery). Additional information has been requested. 1/11/08 Reviewed hospital medical records which reveal patient experienced irritability, black stools & bilious emesis x 12 hours which progressed to bloody stools. Went to outlying ER where gastrograffin enema reveals IS that could not be reduced despite 3 attemps. Transferred to higher level of care for surgical management. Admitted 11/20-11/23/2007. On admit, lethargic, distended abdomen w/epigastric mass palpablel. To OR for exp lap, no bowel resection needed. Did well post op & d/c to home. Final DX: intussusception, surgically reduced. 1/22/08 Reviewed vax record.


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