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This is VAERS ID 303292

History of Changes from the VAERS Wayback Machine

First Appeared on 12/31/2008

303292
VAERS Form:
Age:0.3
Gender:Male
Location:Connecticut
Vaccinated:2007-10-23
Onset:2007-11-08
Submitted:2008-01-22
Entered:2008-01-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B1240B / 1 UN / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0436U / 1 LL / -
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B54007H / 1 LL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0670U / 1 - / PO

Administered by: Other      Purchased by: Unknown
Symptoms: Acidosis, Acute abdomen, Areflexia, Arrhythmia, Abdominal X-ray

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2007-11-10
Permanent Disability? Yes
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit? (V2.0) No
Hospitalized? Yes, days: 1     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Gastroesophageal reflux PMH: otitis media tx starting 11/8/07.
Allergies:
Diagnostic Lab Data: Unknown ER LABS: ABG pH 6.85 (H). CXR & abdominal x-ray revealed multiple dilated loops of air-filled small bowel & free intraperitoneal air. 4/15/08 Additional labs received from CDC: small intestine w/marked & extensive congestion o
CDC 'Split Type':

Write-up:Information has been received from a physician concerning an approximately 5 month old male with a history of /"reflux/" who in approximately October 2007, was vaccinated orally with a second dose of Rotateq. Two weeks post vaccination, on 08 NOV 2007, th"e patient was seen /"in the office/" at which time the patient was /"congested with on an off vomiting/". The patient presented with /"a good bowel movement/" and was given amoxicillin and sent home. Approximately 16 hours later the patient was taken to t


Changed on 12/8/2009

303292 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Connecticut
Vaccinated:2007-10-23
Onset:2007-11-08
Submitted:2008-01-22
Entered:2008-01-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B1240B / 1 UN / -
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B1240B / 1 UN / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0436U / 1 LL / -
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B54007H / 1 LL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0670U / 1 - / PO

Administered by: Other      Purchased by: Unknown Other
Symptoms: Acidosis, Acute abdomen, Areflexia, Arrhythmia, Blood gases abnormal, Cardio-respiratory arrest, Cardioversion, Chest X-ray abnormal, Compartment syndrome, Convulsion, Crying, Death, Dehydration, Disseminated intravascular coagulation, Gastrointestinal necrosis, Haematochezia, Hepatic congestion, Hepatic failure, Hyperaemia, Hypercapnia, Infection, Intensive care, Intestinal ischaemia, Intubation, Intussusception, Laparotomy, Lethargy, Multi-organ failure, Mydriasis, Peripheral ischaemia, Petechiae, Pupil fixed, Resuscitation, Sepsis, Septic shock, Surgery, Vomiting, X-ray abnormal, Spleen congestion, Respiratory tract congestion, Haemorrhage, Influenza serology negative, Diffuse alveolar damage, Virus serology test, Abdominal X-ray, Caecectomy, Rotavirus test negative, Oral intake reduced, Intestinal congestion

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2007-11-10
Permanent Disability? Yes
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit? (V2.0) No
Hospitalized? Yes, days: 1     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Gastroesophageal reflux PMH: otitis media tx starting 11/8/07.
Allergies:
Diagnostic Lab Data: Unknown ER LABS: ABG pH 6.85 (H). CXR & abdominal x-ray revealed multiple dilated loops of air-filled small bowel & free intraperitoneal air. 4/15/08 Additional labs received from CDC: small intestine w/marked & extensive congestion o
CDC 'Split Type': (blank) WAES0801USA03508

Write-up:Information has been received from a physician concerning an approximately 5 month old male with a history of /"reflux/" "reflux" who in approximately October 2007, was vaccinated orally with a second dose of Rotateq. Two weeks post vaccination, on 08 NOV 2007, th"e the patient was seen /"in "in the office/" office" at which time the patient was /"congested "congested with on an off vomiting/". vomiting". The patient presented with /"a "a good bowel movement/" movement" and was given amoxicillin and sent home. Approximately 16 hours later the patient was taken to t the emergency room (ER). "The child passed away on 10 NOV 2007". The patient''s status was not recovered. The reported cause of death was "necrotic bowel". The adverse events reported were considered to be, Disabling, immediately life threatening by the reporter. Additional information has been requested. 1/25/08 Received vax record which reveal patient also received Pediarix #2 AC21B133AA, Hib #2 Merck lot # 0436U, Prevnar #2 B54007H & Rotateq #2 0670U.. 1/29/08 Reviewed ER medical records of 11/9/07 which reveal patient arrived in cardiopulmonary arrest having been brought to hospital by parent. Had voided & had bloody stool, possibly vomited & had been lethargic prior to coding. Was in severe acidosis, shock, dehydration, hypercarbia, arrhythmia, infection. Resuscitated & transferred to higher level of care ER. FINAL Initial ER DX: abdominal castrophe; respiratory/cardiac arrest; and septic shock. 2/1/08 Reviewed hospital med records which reveal patient transferred from outlying hospital in critical shock condition. Admitted 11/9-11/10/2007 to ICU. Had 36 hour hx of poor feeding, increased crying & developed bilious emesis & bloody stools. Intubated & emergent laparotomy & ileocecectomy was performed in ICU. Finding at surgery: IS extending to hepatic flexure w/small area of necrosis in cecum & entire small bowel w/diffusely involved ischemia thought likely secondary to shock & cardiac arrest. Bowel remained dusky at end of procedure & abdomen left open w/bowel wrapped in order to visulize recovery. develope


Changed on 3/2/2010

303292 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Connecticut
Vaccinated:2007-10-23
Onset:2007-11-08
Submitted:2008-01-22
Entered:2008-01-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B1240B / 1 UN / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0436U / 1 LL / -
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC B54007H / 1 LL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0670U / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Acidosis, Acute abdomen, Areflexia, Arrhythmia, Blood gases abnormal, Cardio-respiratory arrest, Cardioversion, Chest X-ray abnormal, Compartment syndrome, Convulsion, Crying, Death, Dehydration, Disseminated intravascular coagulation, Gastrointestinal necrosis, Haematochezia, Hepatic congestion, Hepatic failure, Hyperaemia, Hypercapnia, Infection, Intensive care, Intestinal ischaemia, Intubation, Intussusception, Laparotomy, Lethargy, Multi-organ failure, Mydriasis, Peripheral ischaemia, Petechiae, Pupil fixed, Resuscitation, Sepsis, Septic shock, Surgery, Vomiting, X-ray abnormal, Spleen congestion, Respiratory tract congestion, Haemorrhage, Influenza serology negative, Diffuse alveolar damage, Virus serology test, Abdominal X-ray, Caecectomy, Rotavirus test negative, Oral intake reduced, Intestinal congestion

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2007-11-10
Permanent Disability? Yes
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit? (V2.0) No
Hospitalized? Yes, days: 1     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Gastroesophageal reflux PMH: otitis media tx starting 11/8/07.
Allergies:
Diagnostic Lab Data: Unknown ER LABS: ABG pH 6.85 (H). CXR & abdominal x-ray revealed multiple dilated loops of air-filled small bowel & free intraperitoneal air. 4/15/08 Additional labs received from CDC: small intestine w/marked & extensive congestion o
CDC 'Split Type': WAES0801USA03508

Write-up:Information has been received from a physician concerning an approximately 5 month old male with a history of "reflux" who in approximately October 2007, was vaccinated orally with a second dose of Rotateq. Two weeks post vaccination, on 08 NOV 2007, the patient was seen "in the office" at which time the patient was "congested with on an off vomiting". The patient presented with "a good bowel movement" and was given amoxicillin and sent home. Approximately 16 hours later the patient was taken to the emergency room (ER). "The child passed away on 10 NOV 2007". The patient''s status was not recovered. The reported cause of death was "necrotic bowel". The adverse events reported were considered to be, Disabling, immediately life threatening by the reporter. Additional information has been requested. 1/25/08 Received vax record which reveal patient also received Pediarix #2 AC21B133AA, Hib #2 Merck lot # 0436U, Prevnar #2 B54007H & Rotateq #2 0670U.. 1/29/08 Reviewed ER medical records of 11/9/07 which reveal patient arrived in cardiopulmonary arrest having been brought to hospital by parent. Had voided & had bloody stool, possibly vomited & had been lethargic prior to coding. Was in severe acidosis, shock, dehydration, hypercarbia, arrhythmia, infection. Resuscitated & transferred to higher level of care ER. FINAL Initial ER DX: abdominal castrophe; respiratory/cardiac arrest; and septic shock. 2/1/08 Reviewed hospital med records which reveal patient transferred from outlying hospital in critical shock condition. Admitted 11/9-11/10/2007 to ICU. Had 36 hour hx of poor feeding, increased crying & developed bilious emesis & bloody stools. Intubated & emergent laparotomy & ileocecectomy was performed in ICU. Finding at surgery: IS extending to hepatic flexure w/small area of necrosis in cecum & entire small bowel w/diffusely involved ischemia thought likely secondary to shock & cardiac arrest. Bowel remained dusky at end of procedure & abdomen left open w/bowel wrapped in order to visulize recovery. develope


Changed on 4/7/2010

303292 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Connecticut
Vaccinated:2007-10-23
Onset:2007-11-08
Submitted:2008-01-22
Entered:2008-01-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B1240B / 1 UN / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0436U / 1 LL / -
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B54007H / 1 LL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0670U / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Acidosis, Acute abdomen, Areflexia, Arrhythmia, Blood gases abnormal, Cardio-respiratory arrest, Cardioversion, Chest X-ray abnormal, Compartment syndrome, Convulsion, Crying, Death, Dehydration, Disseminated intravascular coagulation, Gastrointestinal necrosis, Haematochezia, Hepatic congestion, Hepatic failure, Hyperaemia, Hypercapnia, Infection, Intensive care, Intestinal ischaemia, Intubation, Intussusception, Laparotomy, Lethargy, Multi-organ failure, Mydriasis, Peripheral ischaemia, Petechiae, Pupil fixed, Resuscitation, Sepsis, Septic shock, Surgery, Vomiting, X-ray abnormal, Spleen congestion, Respiratory tract congestion, Haemorrhage, Influenza serology negative, Diffuse alveolar damage, Virus serology test, Abdominal X-ray, Caecectomy, Rotavirus test negative, Oral intake reduced, Intestinal congestion

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2007-11-10
Permanent Disability? Yes
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit? (V2.0) No
Hospitalized? Yes, days: 1     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Gastroesophageal reflux PMH: otitis media tx starting 11/8/07.
Allergies:
Diagnostic Lab Data: Unknown ER LABS: ABG pH 6.85 (H). CXR & abdominal x-ray revealed multiple dilated loops of air-filled small bowel & free intraperitoneal air. 4/15/08 Additional labs received from CDC: small intestine w/marked & extensive congestion o
CDC 'Split Type': WAES0801USA03508

Write-up:Information has been received from a physician concerning an approximately 5 month old male with a history of "reflux" who in approximately October 2007, was vaccinated orally with a second dose of Rotateq. Two weeks post vaccination, on 08 NOV 2007, the patient was seen "in the office" at which time the patient was "congested with on an off vomiting". The patient presented with "a good bowel movement" and was given amoxicillin and sent home. Approximately 16 hours later the patient was taken to the emergency room (ER). "The child passed away on 10 NOV 2007". The patient''s status was not recovered. The reported cause of death was "necrotic bowel". The adverse events reported were considered to be, Disabling, immediately life threatening by the reporter. Additional information has been requested. 1/25/08 Received vax record which reveal patient also received Pediarix #2 AC21B133AA, Hib #2 Merck lot # 0436U, Prevnar #2 B54007H & Rotateq #2 0670U.. 1/29/08 Reviewed ER medical records of 11/9/07 which reveal patient arrived in cardiopulmonary arrest having been brought to hospital by parent. Had voided & had bloody stool, possibly vomited & had been lethargic prior to coding. Was in severe acidosis, shock, dehydration, hypercarbia, arrhythmia, infection. Resuscitated & transferred to higher level of care ER. FINAL Initial ER DX: abdominal castrophe; respiratory/cardiac arrest; and septic shock. 2/1/08 Reviewed hospital med records which reveal patient transferred from outlying hospital in critical shock condition. Admitted 11/9-11/10/2007 to ICU. Had 36 hour hx of poor feeding, increased crying & developed bilious emesis & bloody stools. Intubated & emergent laparotomy & ileocecectomy was performed in ICU. Finding at surgery: IS extending to hepatic flexure w/small area of necrosis in cecum & entire small bowel w/diffusely involved ischemia thought likely secondary to shock & cardiac arrest. Bowel remained dusky at end of procedure & abdomen left open w/bowel wrapped in order to visulize recovery. develope


Changed on 8/31/2010

303292 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Connecticut
Vaccinated:2007-10-23
Onset:2007-11-08
Submitted:2008-01-22
Entered:2008-01-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B1240B / 1 UN / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0436U / 1 LL / -
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH B54007H / 1 LL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0670U / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Acidosis, Acute abdomen, Areflexia, Arrhythmia, Blood gases abnormal, Cardio-respiratory arrest, Cardioversion, Chest X-ray abnormal, Compartment syndrome, Convulsion, Crying, Death, Dehydration, Disseminated intravascular coagulation, Gastrointestinal necrosis, Haematochezia, Hepatic congestion, Hepatic failure, Hyperaemia, Hypercapnia, Infection, Intensive care, Intestinal ischaemia, Intubation, Intussusception, Laparotomy, Lethargy, Multi-organ failure, Mydriasis, Peripheral ischaemia, Petechiae, Pupil fixed, Resuscitation, Sepsis, Septic shock, Surgery, Vomiting, X-ray abnormal, Spleen congestion, Respiratory tract congestion, Haemorrhage, Influenza serology negative, Diffuse alveolar damage, Virus serology test, Abdominal X-ray, Caecectomy, Rotavirus test negative, Oral intake reduced, Intestinal congestion

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2007-11-10
Permanent Disability? Yes
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit? (V2.0) No
Hospitalized? Yes, days: 1     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Gastroesophageal reflux PMH: otitis media tx starting 11/8/07.
Allergies:
Diagnostic Lab Data: Unknown ER LABS: ABG pH 6.85 (H). CXR & abdominal x-ray revealed multiple dilated loops of air-filled small bowel & free intraperitoneal air. 4/15/08 Additional labs received from CDC: small intestine w/marked & extensive congestion o
CDC 'Split Type': WAES0801USA03508

Write-up:Information has been received from a physician concerning an approximately 5 month old male with a history of "reflux" who in approximately October 2007, was vaccinated orally with a second dose of Rotateq. Two weeks post vaccination, on 08 NOV 2007, the patient was seen "in the office" at which time the patient was "congested with on an off vomiting". The patient presented with "a good bowel movement" and was given amoxicillin and sent home. Approximately 16 hours later the patient was taken to the emergency room (ER). "The child passed away on 10 NOV 2007". The patient''s status was not recovered. The reported cause of death was "necrotic bowel". The adverse events reported were considered to be, Disabling, immediately life threatening by the reporter. Additional information has been requested. 1/25/08 Received vax record which reveal patient also received Pediarix #2 AC21B133AA, Hib #2 Merck lot # 0436U, Prevnar #2 B54007H & Rotateq #2 0670U.. 1/29/08 Reviewed ER medical records of 11/9/07 which reveal patient arrived in cardiopulmonary arrest having been brought to hospital by parent. Had voided & had bloody stool, possibly vomited & had been lethargic prior to coding. Was in severe acidosis, shock, dehydration, hypercarbia, arrhythmia, infection. Resuscitated & transferred to higher level of care ER. FINAL Initial ER DX: abdominal castrophe; respiratory/cardiac arrest; and septic shock. 2/1/08 Reviewed hospital med records which reveal patient transferred from outlying hospital in critical shock condition. Admitted 11/9-11/10/2007 to ICU. Had 36 hour hx of poor feeding, increased crying & developed bilious emesis & bloody stools. Intubated & emergent laparotomy & ileocecectomy was performed in ICU. Finding at surgery: IS extending to hepatic flexure w/small area of necrosis in cecum & entire small bowel w/diffusely involved ischemia thought likely secondary to shock & cardiac arrest. Bowel remained dusky at end of procedure & abdomen left open w/bowel wrapped in order to visulize recovery. develope


Changed on 5/13/2013

303292 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Connecticut
Vaccinated:2007-10-23
Onset:2007-11-08
Submitted:2008-01-22
Entered:2008-01-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B1240B / 1 UN / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0436U / 1 LL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B54007H / 1 LL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0670U / 1 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0670U / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Acidosis, Acute abdomen, Areflexia, Arrhythmia, Blood gases abnormal, Cardio-respiratory arrest, Cardioversion, Chest X-ray abnormal, Compartment syndrome, Convulsion, Crying, Death, Dehydration, Disseminated intravascular coagulation, Gastrointestinal necrosis, Haematochezia, Hepatic congestion, Hepatic failure, Hyperaemia, Hypercapnia, Infection, Intensive care, Intestinal ischaemia, Intubation, Intussusception, Laparotomy, Lethargy, Multi-organ failure, Mydriasis, Peripheral ischaemia, Petechiae, Pupil fixed, Resuscitation, Sepsis, Septic shock, Surgery, Vomiting, X-ray abnormal, Spleen congestion, Respiratory tract congestion, Haemorrhage, Influenza serology negative, Diffuse alveolar damage, Virus serology test, Abdominal X-ray, Caecectomy, Rotavirus test negative, Oral intake reduced, Intestinal congestion

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2007-11-10
Permanent Disability? Yes
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit? (V2.0) No
Hospitalized? Yes, days: 1     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Gastroesophageal reflux PMH: otitis media tx starting 11/8/07.
Allergies:
Diagnostic Lab Data: Unknown ER LABS: ABG pH 6.85 (H). CXR & abdominal x-ray revealed multiple dilated loops of air-filled small bowel & free intraperitoneal air. 4/15/08 Additional labs received from CDC: small intestine w/marked & extensive congestion o
CDC 'Split Type': WAES0801USA03508

Write-up:Information has been received from a physician concerning an approximately 5 month old male with a history of "reflux" who in approximately October 2007, was vaccinated orally with a second dose of Rotateq. Two weeks post vaccination, on 08 NOV 2007, the patient was seen "in the office" at which time the patient was "congested with on an off vomiting". The patient presented with "a good bowel movement" and was given amoxicillin and sent home. Approximately 16 hours later the patient was taken to the emergency room (ER). "The child passed away on 10 NOV 2007". The patient''s status was not recovered. The reported cause of death was "necrotic bowel". The adverse events reported were considered to be, Disabling, immediately life threatening by the reporter. Additional information has been requested. 1/25/08 Received vax record which reveal patient also received Pediarix #2 AC21B133AA, Hib #2 Merck lot # 0436U, Prevnar #2 B54007H & Rotateq #2 0670U.. 1/29/08 Reviewed ER medical records of 11/9/07 which reveal patient arrived in cardiopulmonary arrest having been brought to hospital by parent. Had voided & had bloody stool, possibly vomited & had been lethargic prior to coding. Was in severe acidosis, shock, dehydration, hypercarbia, arrhythmia, infection. Resuscitated & transferred to higher level of care ER. FINAL Initial ER DX: abdominal castrophe; respiratory/cardiac arrest; and septic shock. 2/1/08 Reviewed hospital med records which reveal patient transferred from outlying hospital in critical shock condition. Admitted 11/9-11/10/2007 to ICU. Had 36 hour hx of poor feeding, increased crying & developed bilious emesis & bloody stools. Intubated & emergent laparotomy & ileocecectomy was performed in ICU. Finding at surgery: IS extending to hepatic flexure w/small area of necrosis in cecum & entire small bowel w/diffusely involved ischemia thought likely secondary to shock & cardiac arrest. Bowel remained dusky at end of procedure & abdomen left open w/bowel wrapped in order to visulize recovery. develope


Changed on 2/14/2017

303292 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Connecticut
Vaccinated:2007-10-23
Onset:2007-11-08
Submitted:2008-01-22
Entered:2008-01-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B1240B / 1 UN / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0436U / 1 LL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B54007H / 1 LL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0670U / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Acidosis, Acute abdomen, Areflexia, Arrhythmia, Blood gases abnormal, Cardio-respiratory arrest, Cardioversion, Chest X-ray abnormal, Compartment syndrome, Convulsion, Crying, Death, Dehydration, Disseminated intravascular coagulation, Gastrointestinal necrosis, Haematochezia, Hepatic congestion, Hepatic failure, Hyperaemia, Hypercapnia, Infection, Intensive care, Intestinal ischaemia, Intubation, Intussusception, Laparotomy, Lethargy, Multi-organ failure, Mydriasis, Peripheral ischaemia, Petechiae, Pupil fixed, Resuscitation, Sepsis, Septic shock, Surgery, Vomiting, X-ray abnormal, Spleen congestion, Respiratory tract congestion, Haemorrhage, Influenza serology negative, Diffuse alveolar damage, Virus serology test, Abdominal X-ray, Caecectomy, Rotavirus test negative, Oral intake reduced, Intestinal congestion

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2007-11-10
Permanent Disability? Yes
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit? (V2.0) No
Hospitalized? Yes, days: 1     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Gastroesophageal reflux PMH: otitis media tx starting 11/8/07.
Allergies:
Diagnostic Lab Data: Unknown ER LABS: ABG pH 6.85 (H). CXR & abdominal x-ray revealed multiple dilated loops of air-filled small bowel & free intraperitoneal air. 4/15/08 Additional labs received from CDC: small intestine w/marked & extensive congestion o of submucosa w/hemorrhages & necrosis; congestion of liver & spleen. Adenovirus, Rotavirus & haemophilus all neg.
CDC 'Split Type': WAES0801USA03508

Write-up:Information has been received from a physician concerning an approximately 5 month old male with a history of "reflux" who in approximately October 2007, was vaccinated orally with a second dose of Rotateq. Two weeks post vaccination, on 08 NOV 2007, the patient was seen "in the office" at which time the patient was "congested with on an off vomiting". The patient presented with "a good bowel movement" and was given amoxicillin and sent home. Approximately 16 hours later the patient was taken to the emergency room (ER). "The child passed away on 10 NOV 2007". The patient''s status was not recovered. The reported cause of death was "necrotic bowel". The adverse events reported were considered to be, Disabling, immediately life threatening by the reporter. Additional information has been requested. 1/25/08 Received vax record which reveal patient also received Pediarix #2 AC21B133AA, Hib #2 Merck lot # 0436U, Prevnar #2 B54007H & Rotateq #2 0670U.. 1/29/08 Reviewed ER medical records of 11/9/07 which reveal patient arrived in cardiopulmonary arrest having been brought to hospital by parent. Had voided & had bloody stool, possibly vomited & had been lethargic prior to coding. Was in severe acidosis, shock, dehydration, hypercarbia, arrhythmia, infection. Resuscitated & transferred to higher level of care ER. FINAL Initial ER DX: abdominal castrophe; respiratory/cardiac arrest; and septic shock. 2/1/08 Reviewed hospital med records which reveal patient transferred from outlying hospital in critical shock condition. Admitted 11/9-11/10/2007 to ICU. Had 36 hour hx of poor feeding, increased crying & developed bilious emesis & bloody stools. Intubated & emergent laparotomy & ileocecectomy was performed in ICU. Finding at surgery: IS extending to hepatic flexure w/small area of necrosis in cecum & entire small bowel w/diffusely involved ischemia thought likely secondary to shock & cardiac arrest. Bowel remained dusky at end of procedure & abdomen left open w/bowel wrapped in order to visulize recovery. develope developed compartment syndrome of bilateral legs. Deteriorated, developed hepatic failure, DIC, fixed & dilated pupils, seizures & absent reflexes. Defibrillated numerous times & expired 11/10/07. Preliminary autopsy report included w/medical records reveals COD as Intussusception leading to ischemic bowel resulting in sepsis complicated by prolonged cardiac arrest & multiorgan failure. Findings included: ischemic bowel; diffuse alveolar damage,mild; sepsis; hepatic failure; DIC; renal petechiae; gastric mucosal petechiae; bilateral lower extremity ischemic damage; hyperemic lower extremities.


Changed on 9/14/2017

303292 Before After
VAERS Form:(blank) 1
Age:0.3
Gender:Male
Location:Connecticut
Vaccinated:2007-10-23
Onset:2007-11-08
Submitted:2008-01-22
Entered:2008-01-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B1240B / 1 2 UN / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0436U / 1 2 LL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B54007H / 1 2 LL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0670U / 1 2 - MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Death, Vomiting, Respiratory tract congestion

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2007-11-10
Permanent Disability? Yes
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit? (V2.0) No
Hospitalized? Yes, days: 1     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Gastroesophageal reflux PMH: otitis media tx starting 11/8/07.
Allergies:
Diagnostic Lab Data: Unknown ER LABS: ABG pH 6.85 (H). CXR & abdominal x-ray revealed multiple dilated loops of air-filled small bowel & free intraperitoneal air. 4/15/08 Additional labs received from CDC: small intestine w/marked & extensive congestion of submucosa w/hemorrhages & necrosis; congestion of liver & spleen. Adenovirus, Rotavirus & haemophilus all neg.
CDC 'Split Type': WAES0801USA03508

Write-up:Information has been received from a physician concerning an approximately 5 month old male with a history of "reflux" who in approximately October 2007, was vaccinated orally with a second dose of Rotateq. Two weeks post vaccination, on 08 NOV 2007, the patient was seen "in the office" at which time the patient was "congested with on an off vomiting". The patient presented with "a good bowel movement" and was given amoxicillin and sent home. Approximately 16 hours later the patient was taken to the emergency room (ER). "The child passed away on 10 NOV 2007". The patient''s status was not recovered. The reported cause of death was "necrotic bowel". The adverse events reported were considered to be, Disabling, immediately life threatening by the reporter. Additional information has been requested. 1/25/08 Received vax record which reveal patient also received Pediarix #2 AC21B133AA, Hib #2 Merck lot # 0436U, Prevnar #2 B54007H & Rotateq #2 0670U.. 1/29/08 Reviewed ER medical records of 11/9/07 which reveal patient arrived in cardiopulmonary arrest having been brought to hospital by parent. Had voided & had bloody stool, possibly vomited & had been lethargic prior to coding. Was in severe acidosis, shock, dehydration, hypercarbia, arrhythmia, infection. Resuscitated & transferred to higher level of care ER. FINAL Initial ER DX: abdominal castrophe; respiratory/cardiac arrest; and septic shock. 2/1/08 Reviewed hospital med records which reveal patient transferred from outlying hospital in critical shock condition. Admitted 11/9-11/10/2007 to ICU. Had 36 hour hx of poor feeding, increased crying & developed bilious emesis & bloody stools. Intubated & emergent laparotomy & ileocecectomy was performed in ICU. Finding at surgery: IS extending to hepatic flexure w/small area of necrosis in cecum & entire small bowel w/diffusely involved ischemia thought likely secondary to shock & cardiac arrest. Bowel remained dusky at end of procedure & abdomen left open w/bowel wrapped in order to visulize recovery. developed compartment syndrome of bilateral legs. Deteriorated, developed hepatic failure, DIC, fixed & dilated pupils, seizures & absent reflexes. Defibrillated numerous times & expired 11/10/07. Preliminary autopsy report included w/medical records reveals COD as Intussusception leading to ischemic bowel resulting in sepsis complicated by prolonged cardiac arrest & multiorgan failure. Findings included: ischemic bowel; diffuse alveolar damage,mild; sepsis; hepatic failure; DIC; renal petechiae; gastric mucosal petechiae; bilateral lower extremity ischemic damage; hyperemic lower extremities.


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