| VAERS ID: |
336841 (history) |
| Form: |
Version .0 |
| Age: |
0.2 |
| Gender: |
Female |
| Location: |
Illinois |
| Vaccinated: | 2008-11-18 |
| Onset: | 2008-12-04 |
| Days after vaccination: | 16 |
| Submitted: |
2009-01-09 |
| Days after onset: | 36 |
| Entered: |
2009-01-08 |
| Days after submission: | 1 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR |
C2956AA / 0 |
LL / IM |
| HIBV: HIB (ACTHIB) / SANOFI PASTEUR |
UF515AA / 0 |
RL / IM |
| IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR |
A0836 / 0 |
RL / IM |
| PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC |
C68309 / 0 |
LL / IM |
| ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. |
0641X / 0 |
- / PO |
Administered by: Private Purchased by: Private
Symptoms: Autopsy,
Death,
Inflammation,
Intussusception,
Nasopharyngitis,
Pneumonia,
Pyrexia,
Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2008-12-04
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None except runny nose
Preexisting Conditions: Pre-maturity
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: Patient found unresponsive in crib by parents. No symptoms prior - autopsy revealed intussusception. Pronounced dead at ER. 1/23/09 Autopsy report states COD as complications of intussusception. Also states: six areas of IS of small intestine; changes of distant intestine present; early pneumonia; inflammation of lung tissue & small airways. Patient had been found unresponsive in crib after recent history of cold like symptoms with fever. |
