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. |