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This is VAERS ID 321722

History of Changes from the VAERS Wayback Machine

First Appeared on 12/31/2008

VAERS ID: 321722
VAERS Form:
Age:0.5
Gender:Female
Location:Tennessee
Vaccinated:2007-10-05
Onset:2008-02-20
Submitted:2008-08-08
Entered:2008-08-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B127A / 2 LL / IM
FLU: INFLUENZA (FLUZONE) / SANOFI PASTEUR U2442A / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1053U / 2 - / PO

Administered by: Other      Purchased by: Unknown
Symptoms: Abdominal distension, Abdominal pain, Blood creatinine decreased, Abnormal behaviour, Abdominal X-ray

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
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? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown LABS: CT abdomen/pelvis revealed large bowel gas loops. Abdominal x-ray. CBC w/hematocrit 36.6(L) & neutros 22%(L). CO2 18.7(L), creatinine 0.22(L). Stool culture neg. US of abdomen c/w mesenteric adenitis but no IS.
CDC 'Split Type':

Write-up: Information has been received from a physician and a nurse concerning a 10 month old female who on 19-JUN-2007 was vaccinated with a first dose of ROTATEQ oral. On 07-AUG-2007 the patient was vaccinated with a second dose of ROTATEQ (lot# 657515/0668U) o"ral. On 05-OCT-2007 the patient was vaccinated with a third dose of ROTATEQ (lot# 657045/1053U) oral. Concomitant therapy on 05-OCT-2007 included PREVNAR and PEDIARIX. On 20-FEB-2008 the patient experienced vomiting and diarrhea. The patient was taken


Changed on 12/8/2009

VAERS ID: 321722 Before After
VAERS Form:
Age:0.5
Gender:Female
Location:Tennessee
Vaccinated:2007-10-05
Onset:2008-02-20
Submitted:2008-08-08
Entered:2008-08-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B127A / 2 LL / IM
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B127A / 2 LL / IM
FLU: INFLUENZA (FLUZONE) INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U2442A / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1053U / 2 - / PO

Administered by: Other      Purchased by: Unknown Other
Symptoms: Abdominal distension, Abdominal pain, Blood creatinine decreased, Carbon dioxide decreased, Computerised tomogram abnormal, Culture stool negative, Diarrhoea, Full blood count abnormal, Gastroenteritis, Haematocrit decreased, Intussusception, Irritability, Lymphadenitis, Nausea, Pyrexia, Vomiting, Ultrasound abdomen abnormal, Ear discomfort, Neutrophil percentage decreased, Urine output decreased, Abnormal behaviour, Abdominal X-ray

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
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? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown LABS: CT abdomen/pelvis revealed large bowel gas loops. Abdominal x-ray. CBC w/hematocrit 36.6(L) & neutros 22%(L). CO2 18.7(L), creatinine 0.22(L). Stool culture neg. US of abdomen c/w mesenteric adenitis but no IS.
CDC 'Split Type': (blank) WAES0807USA05710

Write-up: Information has been received from a physician and a nurse concerning a 10 month old female who on 19-JUN-2007 was vaccinated with a first dose of ROTATEQ oral. On 07-AUG-2007 the patient was vaccinated with a second dose of ROTATEQ (lot# 657515/0668U) o"ral. oral. On 05-OCT-2007 the patient was vaccinated with a third dose of ROTATEQ (lot# 657045/1053U) oral. Concomitant therapy on 05-OCT-2007 included PREVNAR and PEDIARIX. On 20-FEB-2008 the patient experienced vomiting and diarrhea. The patient was taken to the hospital and was diagnosed with intussusception. A CT scan was performed with no result provided. The patient was then airlifted to a different hospital. When the patient got to that hospital the intussusception was gone. Intussusception was considered to be disabling and immediately life-threatening. Additional information has been requested. 8/19/08 Reviewed hospital medical records of 2/21/2008. FINAL DX: gastroenteritis; IS spontaneously resolved Records reveal patient had been transferred via helicopter from outlying ER with diagnosis of intussusception. Patient had experienced abdominal pain x 2 days w/nausea, vomiting, copious watery diarrhea, decreased urine output & irritability. In outlying ER had abdominal distention. CT scan done which was c/w IS & transferred to higher level of care. Surgical consult done. Tolerated PO fluids in ER & d/c to home. 8/26/08 Reviewed ER medical records of 2/20/2008. FINAL DX: Intussusception Records reveal patient experienced vomiting, diarrhea & reduced oral intake x 2 days. In ER had fever 101, pulling at ears, behaving abnormally, decreased urine output, no tears w/crying. Transferred to higher level of care.


Changed on 5/13/2013

VAERS ID: 321722 Before After
VAERS Form:
Age:0.5
Gender:Female
Location:Tennessee
Vaccinated:2007-10-05
Onset:2008-02-20
Submitted:2008-08-08
Entered:2008-08-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B127A / 2 LL / IM
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U2442A / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1053U / 2 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1053U / 2 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal distension, Abdominal pain, Blood creatinine decreased, Carbon dioxide decreased, Computerised tomogram abnormal, Culture stool negative, Diarrhoea, Full blood count abnormal, Gastroenteritis, Haematocrit decreased, Intussusception, Irritability, Lymphadenitis, Nausea, Pyrexia, Vomiting, Ultrasound abdomen abnormal, Ear discomfort, Neutrophil percentage decreased, Urine output decreased, Abnormal behaviour, Abdominal X-ray

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
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? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown LABS: CT abdomen/pelvis revealed large bowel gas loops. Abdominal x-ray. CBC w/hematocrit 36.6(L) & neutros 22%(L). CO2 18.7(L), creatinine 0.22(L). Stool culture neg. US of abdomen c/w mesenteric adenitis but no IS.
CDC 'Split Type': WAES0807USA05710

Write-up: Information has been received from a physician and a nurse concerning a 10 month old female who on 19-JUN-2007 was vaccinated with a first dose of ROTATEQ oral. On 07-AUG-2007 the patient was vaccinated with a second dose of ROTATEQ (lot# 657515/0668U) oral. On 05-OCT-2007 the patient was vaccinated with a third dose of ROTATEQ (lot# 657045/1053U) oral. Concomitant therapy on 05-OCT-2007 included PREVNAR and PEDIARIX. On 20-FEB-2008 the patient experienced vomiting and diarrhea. The patient was taken to the hospital and was diagnosed with intussusception. A CT scan was performed with no result provided. The patient was then airlifted to a different hospital. When the patient got to that hospital the intussusception was gone. Intussusception was considered to be disabling and immediately life-threatening. Additional information has been requested. 8/19/08 Reviewed hospital medical records of 2/21/2008. FINAL DX: gastroenteritis; IS spontaneously resolved Records reveal patient had been transferred via helicopter from outlying ER with diagnosis of intussusception. Patient had experienced abdominal pain x 2 days w/nausea, vomiting, copious watery diarrhea, decreased urine output & irritability. In outlying ER had abdominal distention. CT scan done which was c/w IS & transferred to higher level of care. Surgical consult done. Tolerated PO fluids in ER & d/c to home. 8/26/08 Reviewed ER medical records of 2/20/2008. FINAL DX: Intussusception Records reveal patient experienced vomiting, diarrhea & reduced oral intake x 2 days. In ER had fever 101, pulling at ears, behaving abnormally, decreased urine output, no tears w/crying. Transferred to higher level of care.


Changed on 7/7/2013

VAERS ID: 321722 Before After
VAERS Form:
Age:0.5
Gender:Female
Location:Tennessee
Vaccinated:2007-10-05
Onset:2008-02-20
Submitted:2008-08-08
Entered:2008-08-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B127A / 2 LL / IM
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U2442A / 0 LL / IM
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U2442A / 0 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1053U / 2 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal distension, Abdominal pain, Blood creatinine decreased, Carbon dioxide decreased, Computerised tomogram abnormal, Culture stool negative, Diarrhoea, Full blood count abnormal, Gastroenteritis, Haematocrit decreased, Intussusception, Irritability, Lymphadenitis, Nausea, Pyrexia, Vomiting, Ultrasound abdomen abnormal, Ear discomfort, Neutrophil percentage decreased, Urine output decreased, Abnormal behaviour, Abdominal X-ray

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
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? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown LABS: CT abdomen/pelvis revealed large bowel gas loops. Abdominal x-ray. CBC w/hematocrit 36.6(L) & neutros 22%(L). CO2 18.7(L), creatinine 0.22(L). Stool culture neg. US of abdomen c/w mesenteric adenitis but no IS.
CDC 'Split Type': WAES0807USA05710

Write-up: Information has been received from a physician and a nurse concerning a 10 month old female who on 19-JUN-2007 was vaccinated with a first dose of ROTATEQ oral. On 07-AUG-2007 the patient was vaccinated with a second dose of ROTATEQ (lot# 657515/0668U) oral. On 05-OCT-2007 the patient was vaccinated with a third dose of ROTATEQ (lot# 657045/1053U) oral. Concomitant therapy on 05-OCT-2007 included PREVNAR and PEDIARIX. On 20-FEB-2008 the patient experienced vomiting and diarrhea. The patient was taken to the hospital and was diagnosed with intussusception. A CT scan was performed with no result provided. The patient was then airlifted to a different hospital. When the patient got to that hospital the intussusception was gone. Intussusception was considered to be disabling and immediately life-threatening. Additional information has been requested. 8/19/08 Reviewed hospital medical records of 2/21/2008. FINAL DX: gastroenteritis; IS spontaneously resolved Records reveal patient had been transferred via helicopter from outlying ER with diagnosis of intussusception. Patient had experienced abdominal pain x 2 days w/nausea, vomiting, copious watery diarrhea, decreased urine output & irritability. In outlying ER had abdominal distention. CT scan done which was c/w IS & transferred to higher level of care. Surgical consult done. Tolerated PO fluids in ER & d/c to home. 8/26/08 Reviewed ER medical records of 2/20/2008. FINAL DX: Intussusception Records reveal patient experienced vomiting, diarrhea & reduced oral intake x 2 days. In ER had fever 101, pulling at ears, behaving abnormally, decreased urine output, no tears w/crying. Transferred to higher level of care.


Changed on 4/14/2017

VAERS ID: 321722 Before After
VAERS Form:
Age:0.5
Gender:Female
Location:Tennessee
Vaccinated:2007-10-05
Onset:2008-02-20
Submitted:2008-08-08
Entered:2008-08-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B127A / 2 LL / IM
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U2442A / 0 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1053U / 2 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal distension, Abdominal pain, Blood creatinine decreased, Carbon dioxide decreased, Computerised tomogram abnormal, Culture stool negative, Diarrhoea, Full blood count abnormal, Gastroenteritis, Haematocrit decreased, Intussusception, Irritability, Lymphadenitis, Nausea, Pyrexia, Vomiting, Ultrasound abdomen abnormal, Ear discomfort, Neutrophil percentage decreased, Urine output decreased, Abnormal behaviour, Abdominal X-ray

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
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? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown LABS: CT abdomen/pelvis revealed large bowel gas loops. Abdominal x-ray. CBC w/hematocrit 36.6(L) & neutros 22%(L). CO2 18.7(L), creatinine 0.22(L). Stool culture neg. US of abdomen c/w mesenteric adenitis but no IS.
CDC 'Split Type': WAES0807USA05710

Write-up: Information has been received from a physician and a nurse concerning a 10 month old female who on 19-JUN-2007 was vaccinated with a first dose of ROTATEQ oral. On 07-AUG-2007 the patient was vaccinated with a second dose of ROTATEQ (lot# 657515/0668U) oral. On 05-OCT-2007 the patient was vaccinated with a third dose of ROTATEQ (lot# 657045/1053U) oral. Concomitant therapy on 05-OCT-2007 included PREVNAR and PEDIARIX. On 20-FEB-2008 the patient experienced vomiting and diarrhea. The patient was taken to the hospital and was diagnosed with intussusception. A CT scan was performed with no result provided. The patient was then airlifted to a different hospital. When the patient got to that hospital the intussusception was gone. Intussusception was considered to be disabling and immediately life-threatening. Additional information has been requested. 8/19/08 Reviewed hospital medical records of 2/21/2008. FINAL DX: gastroenteritis; IS spontaneously resolved Records reveal patient had been transferred via helicopter from outlying ER with diagnosis of intussusception. Patient had experienced abdominal pain x 2 days w/nausea, vomiting, copious watery diarrhea, decreased urine output & irritability. In outlying ER had abdominal distention. CT scan done which was c/w IS & transferred to higher level of care. Surgical consult done. Tolerated PO fluids in ER & d/c to home. 8/26/08 Reviewed ER medical records of 2/20/2008. FINAL DX: Intussusception Records reveal patient experienced vomiting, diarrhea & reduced oral intake x 2 days. In ER had fever 101, pulling at ears, behaving abnormally, decreased urine output, no tears w/crying. Transferred to higher level of care.


Changed on 9/14/2017

VAERS ID: 321722 Before After
VAERS Form:(blank) 1
Age:0.5
Gender:Female
Location:Tennessee
Vaccinated:2007-10-05
Onset:2008-02-20
Submitted:2008-08-08
Entered:2008-08-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B127A / 2 3 LL / IM
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U2442A / 0 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1053U / 2 3 - MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Diarrhoea, Intussusception, Vomiting

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
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? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown LABS: CT abdomen/pelvis revealed large bowel gas loops. Abdominal x-ray. CBC w/hematocrit 36.6(L) & neutros 22%(L). CO2 18.7(L), creatinine 0.22(L). Stool culture neg. US of abdomen c/w mesenteric adenitis but no IS.
CDC 'Split Type': WAES0807USA05710

Write-up: Information has been received from a physician and a nurse concerning a 10 month old female who on 19-JUN-2007 was vaccinated with a first dose of ROTATEQ oral. On 07-AUG-2007 the patient was vaccinated with a second dose of ROTATEQ (lot# 657515/0668U) oral. On 05-OCT-2007 the patient was vaccinated with a third dose of ROTATEQ (lot# 657045/1053U) oral. Concomitant therapy on 05-OCT-2007 included PREVNAR and PEDIARIX. On 20-FEB-2008 the patient experienced vomiting and diarrhea. The patient was taken to the hospital and was diagnosed with intussusception. A CT scan was performed with no result provided. The patient was then airlifted to a different hospital. When the patient got to that hospital the intussusception was gone. Intussusception was considered to be disabling and immediately life-threatening. Additional information has been requested. 8/19/08 Reviewed hospital medical records of 2/21/2008. FINAL DX: gastroenteritis; IS spontaneously resolved Records reveal patient had been transferred via helicopter from outlying ER with diagnosis of intussusception. Patient had experienced abdominal pain x 2 days w/nausea, vomiting, copious watery diarrhea, decreased urine output & irritability. In outlying ER had abdominal distention. CT scan done which was c/w IS & transferred to higher level of care. Surgical consult done. Tolerated PO fluids in ER & d/c to home. 8/26/08 Reviewed ER medical records of 2/20/2008. FINAL DX: Intussusception Records reveal patient experienced vomiting, diarrhea & reduced oral intake x 2 days. In ER had fever 101, pulling at ears, behaving abnormally, decreased urine output, no tears w/crying. Transferred to higher level of care.


Changed on 2/14/2018

VAERS ID: 321722 Before After
VAERS Form:1
Age:0.5
Gender:Female
Location:Tennessee
Vaccinated:2007-10-05
Onset:2008-02-20
Submitted:2008-08-08
Entered:2008-08-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B127A / 3 LL / IM
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U2442A / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1053U / 3 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Diarrhoea, Intussusception, Vomiting

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
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? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown LABS: CT abdomen/pelvis revealed large bowel gas loops. Abdominal x-ray. CBC w/hematocrit 36.6(L) & neutros 22%(L). CO2 18.7(L), creatinine 0.22(L). Stool culture neg. US of abdomen c/w mesenteric adenitis but no IS.
CDC 'Split Type': WAES0807USA05710

Write-up: Information has been received from a physician and a nurse concerning a 10 month old female who on 19-JUN-2007 was vaccinated with a first dose of ROTATEQ oral. On 07-AUG-2007 the patient was vaccinated with a second dose of ROTATEQ (lot# 657515/0668U) oral. On 05-OCT-2007 the patient was vaccinated with a third dose of ROTATEQ (lot# 657045/1053U) oral. Concomitant therapy on 05-OCT-2007 included PREVNAR and PEDIARIX. On 20-FEB-2008 the patient experienced vomiting and diarrhea. The patient was taken to the hospital and was diagnosed with intussusception. A CT scan was performed with no result provided. The patient was then airlifted to a different hospital. When the patient got to that hospital the intussusception was gone. Intussusception was considered to be disabling and immediately life-threatening. Additional information has been requested. 8/19/08 Reviewed hospital medical records of 2/21/2008. FINAL DX: gastroenteritis; IS spontaneously resolved Records reveal patient had been transferred via helicopter from outlying ER with diagnosis of intussusception. Patient had experienced abdominal pain x 2 days w/nausea, vomiting, copious watery diarrhea, decreased urine output & irritability. In outlying ER had abdominal distention. CT scan done which was c/w IS & transferred to higher level of care. Surgical consult done. Tolerated PO fluids in ER & d/c to home. 8/26/08 Reviewed ER medical records of 2/20/2008. FINAL DX: Intussusception Records reveal patient experienced vomiting, diarrhea & reduced oral intake x 2 days. In ER had fever 101, pulling at ears, behaving abnormally, decreased urine output, no tears w/crying. Transferred to higher level of care.


Changed on 6/14/2018

VAERS ID: 321722 Before After
VAERS Form:1
Age:0.5
Gender:Female
Location:Tennessee
Vaccinated:2007-10-05
Onset:2008-02-20
Submitted:2008-08-08
Entered:2008-08-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B127A / 3 LL / IM
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U2442A / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1053U / 3 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Diarrhoea, Intussusception, Vomiting

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
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? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown LABS: CT abdomen/pelvis revealed large bowel gas loops. Abdominal x-ray. CBC w/hematocrit 36.6(L) & neutros 22%(L). CO2 18.7(L), creatinine 0.22(L). Stool culture neg. US of abdomen c/w mesenteric adenitis but no IS.
CDC 'Split Type': WAES0807USA05710

Write-up: Information has been received from a physician and a nurse concerning a 10 month old female who on 19-JUN-2007 was vaccinated with a first dose of ROTATEQ oral. On 07-AUG-2007 the patient was vaccinated with a second dose of ROTATEQ (lot# 657515/0668U) oral. On 05-OCT-2007 the patient was vaccinated with a third dose of ROTATEQ (lot# 657045/1053U) oral. Concomitant therapy on 05-OCT-2007 included PREVNAR and PEDIARIX. On 20-FEB-2008 the patient experienced vomiting and diarrhea. The patient was taken to the hospital and was diagnosed with intussusception. A CT scan was performed with no result provided. The patient was then airlifted to a different hospital. When the patient got to that hospital the intussusception was gone. Intussusception was considered to be disabling and immediately life-threatening. Additional information has been requested. 8/19/08 Reviewed hospital medical records of 2/21/2008. FINAL DX: gastroenteritis; IS spontaneously resolved Records reveal patient had been transferred via helicopter from outlying ER with diagnosis of intussusception. Patient had experienced abdominal pain x 2 days w/nausea, vomiting, copious watery diarrhea, decreased urine output & irritability. In outlying ER had abdominal distention. CT scan done which was c/w IS & transferred to higher level of care. Surgical consult done. Tolerated PO fluids in ER & d/c to home. 8/26/08 Reviewed ER medical records of 2/20/2008. FINAL DX: Intussusception Records reveal patient experienced vomiting, diarrhea & reduced oral intake x 2 days. In ER had fever 101, pulling at ears, behaving abnormally, decreased urine output, no tears w/crying. Transferred to higher level of care.


Changed on 8/14/2018

VAERS ID: 321722 Before After
VAERS Form:1
Age:0.5
Gender:Female
Location:Tennessee
Vaccinated:2007-10-05
Onset:2008-02-20
Submitted:2008-08-08
Entered:2008-08-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B127A / 3 LL / IM
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U2442A / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1053U / 3 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Diarrhoea, Intussusception, Vomiting

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
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? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown LABS: CT abdomen/pelvis revealed large bowel gas loops. Abdominal x-ray. CBC w/hematocrit 36.6(L) & neutros 22%(L). CO2 18.7(L), creatinine 0.22(L). Stool culture neg. US of abdomen c/w mesenteric adenitis but no IS.
CDC 'Split Type': WAES0807USA05710

Write-up: Information has been received from a physician and a nurse concerning a 10 month old female who on 19-JUN-2007 was vaccinated with a first dose of ROTATEQ oral. On 07-AUG-2007 the patient was vaccinated with a second dose of ROTATEQ (lot# 657515/0668U) oral. On 05-OCT-2007 the patient was vaccinated with a third dose of ROTATEQ (lot# 657045/1053U) oral. Concomitant therapy on 05-OCT-2007 included PREVNAR and PEDIARIX. On 20-FEB-2008 the patient experienced vomiting and diarrhea. The patient was taken to the hospital and was diagnosed with intussusception. A CT scan was performed with no result provided. The patient was then airlifted to a different hospital. When the patient got to that hospital the intussusception was gone. Intussusception was considered to be disabling and immediately life-threatening. Additional information has been requested. 8/19/08 Reviewed hospital medical records of 2/21/2008. FINAL DX: gastroenteritis; IS spontaneously resolved Records reveal patient had been transferred via helicopter from outlying ER with diagnosis of intussusception. Patient had experienced abdominal pain x 2 days w/nausea, vomiting, copious watery diarrhea, decreased urine output & irritability. In outlying ER had abdominal distention. CT scan done which was c/w IS & transferred to higher level of care. Surgical consult done. Tolerated PO fluids in ER & d/c to home. 8/26/08 Reviewed ER medical records of 2/20/2008. FINAL DX: Intussusception Records reveal patient experienced vomiting, diarrhea & reduced oral intake x 2 days. In ER had fever 101, pulling at ears, behaving abnormally, decreased urine output, no tears w/crying. Transferred to higher level of care.


Changed on 9/14/2018

VAERS ID: 321722 Before After
VAERS Form:1
Age:0.5
Gender:Female
Location:Tennessee
Vaccinated:2007-10-05
Onset:2008-02-20
Submitted:2008-08-08
Entered:2008-08-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B127A / 3 LL / IM
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U2442A / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1053U / 3 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Diarrhoea, Intussusception, Vomiting

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
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? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown LABS: CT abdomen/pelvis revealed large bowel gas loops. Abdominal x-ray. CBC w/hematocrit 36.6(L) & neutros 22%(L). CO2 18.7(L), creatinine 0.22(L). Stool culture neg. US of abdomen c/w mesenteric adenitis but no IS.
CDC 'Split Type': WAES0807USA05710

Write-up: Information has been received from a physician and a nurse concerning a 10 month old female who on 19-JUN-2007 was vaccinated with a first dose of ROTATEQ oral. On 07-AUG-2007 the patient was vaccinated with a second dose of ROTATEQ (lot# 657515/0668U) oral. On 05-OCT-2007 the patient was vaccinated with a third dose of ROTATEQ (lot# 657045/1053U) oral. Concomitant therapy on 05-OCT-2007 included PREVNAR and PEDIARIX. On 20-FEB-2008 the patient experienced vomiting and diarrhea. The patient was taken to the hospital and was diagnosed with intussusception. A CT scan was performed with no result provided. The patient was then airlifted to a different hospital. When the patient got to that hospital the intussusception was gone. Intussusception was considered to be disabling and immediately life-threatening. Additional information has been requested. 8/19/08 Reviewed hospital medical records of 2/21/2008. FINAL DX: gastroenteritis; IS spontaneously resolved Records reveal patient had been transferred via helicopter from outlying ER with diagnosis of intussusception. Patient had experienced abdominal pain x 2 days w/nausea, vomiting, copious watery diarrhea, decreased urine output & irritability. In outlying ER had abdominal distention. CT scan done which was c/w IS & transferred to higher level of care. Surgical consult done. Tolerated PO fluids in ER & d/c to home. 8/26/08 Reviewed ER medical records of 2/20/2008. FINAL DX: Intussusception Records reveal patient experienced vomiting, diarrhea & reduced oral intake x 2 days. In ER had fever 101, pulling at ears, behaving abnormally, decreased urine output, no tears w/crying. Transferred to higher level of care.


Changed on 10/14/2018

VAERS ID: 321722 Before After
VAERS Form:1
Age:0.5
Gender:Female
Location:Tennessee
Vaccinated:2007-10-05
Onset:2008-02-20
Submitted:2008-08-08
Entered:2008-08-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B127A / 3 LL / IM
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U2442A / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1053U / 3 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Diarrhoea, Intussusception, Vomiting

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
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? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown LABS: CT abdomen/pelvis revealed large bowel gas loops. Abdominal x-ray. CBC w/hematocrit 36.6(L) & neutros 22%(L). CO2 18.7(L), creatinine 0.22(L). Stool culture neg. US of abdomen c/w mesenteric adenitis but no IS.
CDC 'Split Type': WAES0807USA05710

Write-up: Information has been received from a physician and a nurse concerning a 10 month old female who on 19-JUN-2007 was vaccinated with a first dose of ROTATEQ oral. On 07-AUG-2007 the patient was vaccinated with a second dose of ROTATEQ (lot# 657515/0668U) oral. On 05-OCT-2007 the patient was vaccinated with a third dose of ROTATEQ (lot# 657045/1053U) oral. Concomitant therapy on 05-OCT-2007 included PREVNAR and PEDIARIX. On 20-FEB-2008 the patient experienced vomiting and diarrhea. The patient was taken to the hospital and was diagnosed with intussusception. A CT scan was performed with no result provided. The patient was then airlifted to a different hospital. When the patient got to that hospital the intussusception was gone. Intussusception was considered to be disabling and immediately life-threatening. Additional information has been requested. 8/19/08 Reviewed hospital medical records of 2/21/2008. FINAL DX: gastroenteritis; IS spontaneously resolved Records reveal patient had been transferred via helicopter from outlying ER with diagnosis of intussusception. Patient had experienced abdominal pain x 2 days w/nausea, vomiting, copious watery diarrhea, decreased urine output & irritability. In outlying ER had abdominal distention. CT scan done which was c/w IS & transferred to higher level of care. Surgical consult done. Tolerated PO fluids in ER & d/c to home. 8/26/08 Reviewed ER medical records of 2/20/2008. FINAL DX: Intussusception Records reveal patient experienced vomiting, diarrhea & reduced oral intake x 2 days. In ER had fever 101, pulling at ears, behaving abnormally, decreased urine output, no tears w/crying. Transferred to higher level of care.

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