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This is VAERS ID 300429

History of Changes from the VAERS Wayback Machine

First Appeared on 12/31/2007

VAERS ID: 300429
VAERS Form:
Age:0.5
Gender:Male
Location:Virginia
Vaccinated:2007-12-04
Onset:2007-12-18
Submitted:2007-12-19
Entered:2007-12-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2749AA / 2 LL / IM
FLU: INFLUENZA (FLUZONE) / SANOFI PASTEUR UT2456EA / 0 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0169 / 2 LL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B540168 / 2 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0942U / 2 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium enema abnormal, Intussusception, Ultrasound abdomen abnormal, Explorative laparotomy, Bowel movement irregularity

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Two view abdominal showed dilated loops of small bowel: obstruction
CDC 'Split Type':

Write-up: 12-18-07 intussception - having surgery 12-19-07


Changed on 12/8/2009

VAERS ID: 300429 Before After
VAERS Form:
Age:0.5
Gender:Male
Location:Virginia
Vaccinated:2007-12-04
Onset:2007-12-18
Submitted:2007-12-19
Entered:2007-12-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2749AA / 2 LL / IM
FLU: INFLUENZA (FLUZONE) INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT2456EA / 0 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0169 / 2 LL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B540168 / 2 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0942U / 2 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium enema abnormal, Intussusception, Vomiting, X-ray abnormal, X-ray with contrast upper gastrointestinal tract, Ultrasound abdomen abnormal, Explorative laparotomy, Virus serology test positive, Urine output decreased, Rotavirus test negative, Bowel movement irregularity

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Two view abdominal showed dilated loops of small bowel: obstruction 1/9/08-records received-Barium enema incomplete reduction. Upper GI confirms limited ultrasound report, no malrotation, free fluid, favoring intussusception right midabdom
CDC 'Split Type':

Write-up: 12-18-07 intussception - having surgery 12-19-07 1/9/08-records received for DOS 12/18-12/22/07-DC DX: Intussusception. Exploratory laparotomy and reduction of intussusception not reduced by 2 hydrostatic enemas. Day prior to admission vomting and decrease urine. No bowel movement for 2 days.


Changed on 1/5/2010

VAERS ID: 300429 Before After
VAERS Form:
Age:0.5
Gender:Male
Location:Virginia
Vaccinated:2007-12-04
Onset:2007-12-18
Submitted:2007-12-19
Entered:2007-12-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2749AA / 2 LL / IM
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT2456EA / 0 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0169 / 2 LL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B540168 / 2 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0942U / 2 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium enema abnormal, Intussusception, Vomiting, X-ray abnormal, X-ray with contrast upper gastrointestinal tract, Ultrasound abdomen abnormal, Explorative laparotomy, Virus serology test positive, Urine output decreased, Rotavirus test negative, Bowel movement irregularity

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Two view abdominal showed dilated loops of small bowel: obstruction 1/9/08-records received-Barium enema incomplete reduction. Upper GI confirms limited ultrasound report, no malrotation, free fluid, favoring intussusception right midabdom
CDC 'Split Type':

Write-up: 12-18-07 intussception - having surgery 12-19-07 1/9/08-records received for DOS 12/18-12/22/07-DC DX: Intussusception. Exploratory laparotomy and reduction of intussusception not reduced by 2 hydrostatic enemas. Day prior to admission vomting and decrease urine. No bowel movement for 2 days.


Changed on 3/2/2010

VAERS ID: 300429 Before After
VAERS Form:
Age:0.5
Gender:Male
Location:Virginia
Vaccinated:2007-12-04
Onset:2007-12-18
Submitted:2007-12-19
Entered:2007-12-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2749AA / 2 LL / IM
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT2456EA / 0 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0169 / 2 LL / IM
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC B540168 / 2 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0942U / 2 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Intussusception, X-ray abnormal

Life Threatening? Yes
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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Two view abdominal showed dilated loops of small bowel: obstruction 1/9/08-records received-Barium enema incomplete reduction. Upper GI confirms limited ultrasound report, no malrotation, free fluid, favoring intussusception right midabdom
CDC 'Split Type':

Write-up: 12-18-07 intussception - having surgery 12-19-07 1/9/08-records received for DOS 12/18-12/22/07-DC DX: Intussusception. Exploratory laparotomy and reduction of intussusception not reduced by 2 hydrostatic enemas. Day prior to admission vomting and decrease urine. No bowel movement for 2 days.


Changed on 4/7/2010

VAERS ID: 300429 Before After
VAERS Form:
Age:0.5
Gender:Male
Location:Virginia
Vaccinated:2007-12-04
Onset:2007-12-18
Submitted:2007-12-19
Entered:2007-12-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2749AA / 2 LL / IM
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT2456EA / 0 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0169 / 2 LL / IM
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B540168 / 2 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0942U / 2 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Intussusception, X-ray abnormal

Life Threatening? Yes
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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Two view abdominal showed dilated loops of small bowel: obstruction 1/9/08-records received-Barium enema incomplete reduction. Upper GI confirms limited ultrasound report, no malrotation, free fluid, favoring intussusception right midabdom
CDC 'Split Type':

Write-up: 12-18-07 intussception - having surgery 12-19-07 1/9/08-records received for DOS 12/18-12/22/07-DC DX: Intussusception. Exploratory laparotomy and reduction of intussusception not reduced by 2 hydrostatic enemas. Day prior to admission vomting and decrease urine. No bowel movement for 2 days.


Changed on 8/31/2010

VAERS ID: 300429 Before After
VAERS Form:
Age:0.5
Gender:Male
Location:Virginia
Vaccinated:2007-12-04
Onset:2007-12-18
Submitted:2007-12-19
Entered:2007-12-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2749AA / 2 LL / IM
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT2456EA / 0 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0169 / 2 LL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH B540168 / 2 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0942U / 2 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Intussusception, X-ray abnormal

Life Threatening? Yes
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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Two view abdominal showed dilated loops of small bowel: obstruction 1/9/08-records received-Barium enema incomplete reduction. Upper GI confirms limited ultrasound report, no malrotation, free fluid, favoring intussusception right midabdom
CDC 'Split Type':

Write-up: 12-18-07 intussception - having surgery 12-19-07 1/9/08-records received for DOS 12/18-12/22/07-DC DX: Intussusception. Exploratory laparotomy and reduction of intussusception not reduced by 2 hydrostatic enemas. Day prior to admission vomting and decrease urine. No bowel movement for 2 days.


Changed on 1/4/2011

VAERS ID: 300429 Before After
VAERS Form:
Age:0.5
Gender:Male
Location:Virginia
Vaccinated:2007-12-04
Onset:2007-12-18
Submitted:2007-12-19
Entered:2007-12-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2749AA / 2 LL / IM
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT2456EA / 0 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0169 / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B540168 / 2 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0942U / 2 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Intussusception, X-ray abnormal

Life Threatening? Yes
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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Two view abdominal showed dilated loops of small bowel: obstruction 1/9/08-records received-Barium enema incomplete reduction. Upper GI confirms limited ultrasound report, no malrotation, free fluid, favoring intussusception right midabdom midabdomen. 1/12/08-received tissue samples from this patient. Results: The sample was positive for adenovirus and negative for rotavirus.
CDC 'Split Type':

Write-up: 12-18-07 intussception - having surgery 12-19-07 1/9/08-records received for DOS 12/18-12/22/07-DC DX: Intussusception. Exploratory laparotomy and reduction of intussusception not reduced by 2 hydrostatic enemas. Day prior to admission vomting and decrease urine. No bowel movement for 2 days.


Changed on 4/13/2011

VAERS ID: 300429 Before After
VAERS Form:
Age:0.5
Gender:Male
Location:Virginia
Vaccinated:2007-12-04
Onset:2007-12-18
Submitted:2007-12-19
Entered:2007-12-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2749AA / 2 LL / IM
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT2456EA / 0 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0169 / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B540168 / 2 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0942U / 2 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium enema abnormal, Intussusception, Vomiting, X-ray abnormal, X-ray with contrast upper gastrointestinal tract, Ultrasound abdomen abnormal, Explorative laparotomy, Virus serology test positive, Urine output decreased, Rotavirus test negative, Bowel movement irregularity

Life Threatening? Yes
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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Two view abdominal showed dilated loops of small bowel: obstruction 1/9/08-records received-Barium enema incomplete reduction. Upper GI confirms limited ultrasound report, no malrotation, free fluid, favoring intussusception right midabdomen. 1/12/08-received tissue samples from this patient. Results: The sample was positive for adenovirus and negative for rotavirus.
CDC 'Split Type':

Write-up: 12-18-07 intussception - having surgery 12-19-07 1/9/08-records received for DOS 12/18-12/22/07-DC DX: Intussusception. Exploratory laparotomy and reduction of intussusception not reduced by 2 hydrostatic enemas. Day prior to admission vomting and decrease urine. No bowel movement for 2 days.


Changed on 5/13/2011

VAERS ID: 300429 Before After
VAERS Form:
Age:0.5
Gender:Male
Location:Virginia
Vaccinated:2007-12-04
Onset:2007-12-18
Submitted:2007-12-19
Entered:2007-12-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2749AA / 2 LL / IM
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT2456EA / 0 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0169 / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B540168 / 2 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0942U / 2 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium enema abnormal, Intussusception, Vomiting, X-ray abnormal, X-ray with contrast upper gastrointestinal tract, Ultrasound abdomen abnormal, Explorative laparotomy, Virus serology test positive, Urine output decreased, Rotavirus test negative, Bowel movement irregularity

Life Threatening? Yes
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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Two view abdominal showed dilated loops of small bowel: obstruction 1/9/08-records received-Barium enema incomplete reduction. Upper GI confirms limited ultrasound report, no malrotation, free fluid, favoring intussusception right midabdomen. 1/12/08-received tissue samples from this patient. Results: The sample was positive for adenovirus and negative for rotavirus.
CDC 'Split Type':

Write-up: 12-18-07 intussception - having surgery 12-19-07 1/9/08-records received for DOS 12/18-12/22/07-DC DX: Intussusception. Exploratory laparotomy and reduction of intussusception not reduced by 2 hydrostatic enemas. Day prior to admission vomting and decrease urine. No bowel movement for 2 days.


Changed on 6/11/2011

VAERS ID: 300429 Before After
VAERS Form:
Age:0.5
Gender:Male
Location:Virginia
Vaccinated:2007-12-04
Onset:2007-12-18
Submitted:2007-12-19
Entered:2007-12-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2749AA / 2 LL / IM
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT2456EA / 0 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0169 / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B540168 / 2 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0942U / 2 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium enema abnormal, Intussusception, Vomiting, X-ray abnormal, X-ray with contrast upper gastrointestinal tract, Ultrasound abdomen abnormal, Explorative laparotomy, Virus serology test positive, Urine output decreased, Rotavirus test negative, Bowel movement irregularity

Life Threatening? Yes
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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Two view abdominal showed dilated loops of small bowel: obstruction 1/9/08-records received-Barium enema incomplete reduction. Upper GI confirms limited ultrasound report, no malrotation, free fluid, favoring intussusception right midabdomen. 1/12/08-received tissue samples from this patient. Results: The sample was positive for adenovirus and negative for rotavirus.
CDC 'Split Type':

Write-up: 12-18-07 intussception - having surgery 12-19-07 1/9/08-records received for DOS 12/18-12/22/07-DC DX: Intussusception. Exploratory laparotomy and reduction of intussusception not reduced by 2 hydrostatic enemas. Day prior to admission vomting and decrease urine. No bowel movement for 2 days.


Changed on 5/13/2013

VAERS ID: 300429 Before After
VAERS Form:
Age:0.5
Gender:Male
Location:Virginia
Vaccinated:2007-12-04
Onset:2007-12-18
Submitted:2007-12-19
Entered:2007-12-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2749AA / 2 LL / IM
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT2456EA / 0 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0169 / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B540168 / 2 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0942U / 2 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0942U / 2 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium enema abnormal, Intussusception, Vomiting, X-ray abnormal, X-ray with contrast upper gastrointestinal tract, Ultrasound abdomen abnormal, Explorative laparotomy, Virus serology test positive, Urine output decreased, Rotavirus test negative, Bowel movement irregularity

Life Threatening? Yes
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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Two view abdominal showed dilated loops of small bowel: obstruction 1/9/08-records received-Barium enema incomplete reduction. Upper GI confirms limited ultrasound report, no malrotation, free fluid, favoring intussusception right midabdomen. 1/12/08-received tissue samples from this patient. Results: The sample was positive for adenovirus and negative for rotavirus.
CDC 'Split Type':

Write-up: 12-18-07 intussception - having surgery 12-19-07 1/9/08-records received for DOS 12/18-12/22/07-DC DX: Intussusception. Exploratory laparotomy and reduction of intussusception not reduced by 2 hydrostatic enemas. Day prior to admission vomting and decrease urine. No bowel movement for 2 days.


Changed on 7/7/2013

VAERS ID: 300429 Before After
VAERS Form:
Age:0.5
Gender:Male
Location:Virginia
Vaccinated:2007-12-04
Onset:2007-12-18
Submitted:2007-12-19
Entered:2007-12-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2749AA / 2 LL / IM
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT2456EA / 0 RL / IM
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT2456EA / 0 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0169 / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B540168 / 2 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0942U / 2 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium enema abnormal, Intussusception, Vomiting, X-ray abnormal, X-ray with contrast upper gastrointestinal tract, Ultrasound abdomen abnormal, Explorative laparotomy, Virus serology test positive, Urine output decreased, Rotavirus test negative, Bowel movement irregularity

Life Threatening? Yes
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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Two view abdominal showed dilated loops of small bowel: obstruction 1/9/08-records received-Barium enema incomplete reduction. Upper GI confirms limited ultrasound report, no malrotation, free fluid, favoring intussusception right midabdomen. 1/12/08-received tissue samples from this patient. Results: The sample was positive for adenovirus and negative for rotavirus.
CDC 'Split Type':

Write-up: 12-18-07 intussception - having surgery 12-19-07 1/9/08-records received for DOS 12/18-12/22/07-DC DX: Intussusception. Exploratory laparotomy and reduction of intussusception not reduced by 2 hydrostatic enemas. Day prior to admission vomting and decrease urine. No bowel movement for 2 days.


Changed on 6/14/2014

VAERS ID: 300429 Before After
VAERS Form:
Age:0.5
Gender:Male
Location:Virginia
Vaccinated:2007-12-04
Onset:2007-12-18
Submitted:2007-12-19
Entered:2007-12-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2749AA / 2 LL / IM
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT2456EA / 0 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0169 / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B540168 / 2 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0942U / 2 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium enema abnormal, Intussusception, Vomiting, X-ray abnormal, X-ray with contrast upper gastrointestinal tract, Ultrasound abdomen abnormal, Explorative laparotomy, Virus serology test positive, Urine output decreased, Rotavirus test negative, Bowel movement irregularity

Life Threatening? Yes
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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Two view abdominal showed dilated loops of small bowel: obstruction 1/9/08-records received-Barium enema incomplete reduction. Upper GI confirms limited ultrasound report, no malrotation, free fluid, favoring intussusception right midabdomen. 1/12/08-received tissue samples from this patient. Results: The sample was positive for adenovirus and negative for rotavirus.
CDC 'Split Type':

Write-up: 12-18-07 intussception - having surgery 12-19-07 1/9/08-records received for DOS 12/18-12/22/07-DC DX: Intussusception. Exploratory laparotomy and reduction of intussusception not reduced by 2 hydrostatic enemas. Day prior to admission vomting and decrease urine. No bowel movement for 2 days.


Changed on 2/14/2017

VAERS ID: 300429 Before After
VAERS Form:
Age:0.5 0.51
Gender:Male
Location:Virginia
Vaccinated:2007-12-04
Onset:2007-12-18
Submitted:2007-12-19
Entered:2007-12-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2749AA / 2 LL / IM
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT2456EA / 0 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0169 / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B540168 / 2 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0942U / 2 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium enema abnormal, Intussusception, Vomiting, X-ray abnormal, X-ray with contrast upper gastrointestinal tract, Ultrasound abdomen abnormal, Explorative laparotomy, Virus serology test positive, Urine output decreased, Rotavirus test negative, Bowel movement irregularity

Life Threatening? Yes
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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Two view abdominal showed dilated loops of small bowel: obstruction 1/9/08-records received-Barium enema incomplete reduction. Upper GI confirms limited ultrasound report, no malrotation, free fluid, favoring intussusception right midabdomen. 1/12/08-received tissue samples from this patient. Results: The sample was positive for adenovirus and negative for rotavirus.
CDC 'Split Type':

Write-up: 12-18-07 intussception - having surgery 12-19-07 1/9/08-records received for DOS 12/18-12/22/07-DC DX: Intussusception. Exploratory laparotomy and reduction of intussusception not reduced by 2 hydrostatic enemas. Day prior to admission vomting and decrease urine. No bowel movement for 2 days.


Changed on 4/14/2017

VAERS ID: 300429 Before After
VAERS Form:
Age:0.51
Gender:Male
Location:Virginia
Vaccinated:2007-12-04
Onset:2007-12-18
Submitted:2007-12-19
Entered:2007-12-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2749AA / 2 LL / IM
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT2456EA / 0 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0169 / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B540168 / 2 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0942U / 2 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Barium enema abnormal, Intussusception, Vomiting, X-ray abnormal, X-ray with contrast upper gastrointestinal tract, Ultrasound abdomen abnormal, Explorative laparotomy, Virus serology test positive, Urine output decreased, Rotavirus test negative, Bowel movement irregularity

Life Threatening? Yes
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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Two view abdominal showed dilated loops of small bowel: obstruction 1/9/08-records received-Barium enema incomplete reduction. Upper GI confirms limited ultrasound report, no malrotation, free fluid, favoring intussusception right midabdomen. 1/12/08-received tissue samples from this patient. Results: The sample was positive for adenovirus and negative for rotavirus.
CDC 'Split Type':

Write-up: 12-18-07 intussception - having surgery 12-19-07 1/9/08-records received for DOS 12/18-12/22/07-DC DX: Intussusception. Exploratory laparotomy and reduction of intussusception not reduced by 2 hydrostatic enemas. Day prior to admission vomting and decrease urine. No bowel movement for 2 days.


Changed on 9/14/2017

VAERS ID: 300429 Before After
VAERS Form:(blank) 1
Age:0.51
Gender:Male
Location:Virginia
Vaccinated:2007-12-04
Onset:2007-12-18
Submitted:2007-12-19
Entered:2007-12-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2749AA / 2 3 LL / IM
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT2456EA / 0 1 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0169 / 2 3 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B540168 / 2 3 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0942U / 2 3 - MO / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Intussusception, X-ray abnormal

Life Threatening? Yes
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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Two view abdominal showed dilated loops of small bowel: obstruction 1/9/08-records received-Barium enema incomplete reduction. Upper GI confirms limited ultrasound report, no malrotation, free fluid, favoring intussusception right midabdomen. 1/12/08-received tissue samples from this patient. Results: The sample was positive for adenovirus and negative for rotavirus.
CDC 'Split Type':

Write-up: 12-18-07 intussception - having surgery 12-19-07 1/9/08-records received for DOS 12/18-12/22/07-DC DX: Intussusception. Exploratory laparotomy and reduction of intussusception not reduced by 2 hydrostatic enemas. Day prior to admission vomting and decrease urine. No bowel movement for 2 days.


Changed on 2/14/2018

VAERS ID: 300429 Before After
VAERS Form:1
Age:0.51
Gender:Male
Location:Virginia
Vaccinated:2007-12-04
Onset:2007-12-18
Submitted:2007-12-19
Entered:2007-12-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2749AA / 3 LL / IM
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT2456EA / 1 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0169 / 3 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B540168 / 3 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0942U / 3 MO / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Intussusception, X-ray abnormal

Life Threatening? Yes
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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Two view abdominal showed dilated loops of small bowel: obstruction 1/9/08-records received-Barium enema incomplete reduction. Upper GI confirms limited ultrasound report, no malrotation, free fluid, favoring intussusception right midabdomen. 1/12/08-received tissue samples from this patient. Results: The sample was positive for adenovirus and negative for rotavirus.
CDC 'Split Type':

Write-up: 12-18-07 intussception - having surgery 12-19-07 1/9/08-records received for DOS 12/18-12/22/07-DC DX: Intussusception. Exploratory laparotomy and reduction of intussusception not reduced by 2 hydrostatic enemas. Day prior to admission vomting and decrease urine. No bowel movement for 2 days.


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