| VAERS ID: |
302536 (history) |
| Form: |
Version 1.0 |
| Age: |
0.35 |
| Gender: |
Male |
| Location: |
California |
| Vaccinated: | 2007-11-13 |
| Onset: | 2008-01-02 |
| Days after vaccination: | 50 |
| Submitted: |
2008-01-11 |
| Days after onset: | 9 |
| Entered: |
2008-01-11 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS |
AC14B062 / 2 |
LL / IM |
| HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC. |
6376U / 2 |
RL / IM |
| IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR |
A0126 / 2 |
LL / IM |
| PNC: PNEUMO (PREVNAR) / PFIZER/WYETH |
B54015D / 2 |
RL / IM |
| RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. |
1392U / 2 |
MO / PO |
Administered by: Unknown Purchased by: Unknown
Symptoms: Enema administration,
Intussusception,
Irritability,
Ultrasound abdomen abnormal,
Vomiting
SMQs:, Acute pancreatitis (broad), Retroperitoneal fibrosis (broad), Gastrointestinal obstruction (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hostility/aggression (broad), Hypoglycaemia (broad)
Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Tylenol
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: Abdominal U/S: transverse colon intussusception. Labs and Diagnostics: Abd US (+) for IS. Barium enema (+) for IS at level of hepatic flexure.
CDC Split Type:
Write-up: Developed 1 d hx of fussiness and vomiting and found to have intussusception and reduced by barium enema. 01/23/2008 Vax record received and Rotateq Lot # updated. It appears that the reported lot # was for the 9/18/07 dose not the 11/13/07 dose. 5/30/2008 MR received for DOS 1/2-3/2008 with DX: Intussusception. Infant presented to local hospital with belly pain, vomiting and bloody diarrhea. Pt had been feeding poorly and had fewer wet diapers. Reduced by Barium enema and admitted for o/n obs. |
