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This is VAERS ID 341225

History of Changes from the VAERS Wayback Machine

First Appeared on 12/8/2009

VAERS ID: 341225
VAERS Form:
Age:0.3
Sex:Male
Location:Iowa
Vaccinated:2008-11-17
Onset:2008-11-20
Submitted:2009-03-05
Entered:2009-03-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B201BA / 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF515AA / 1 LL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC C68309 / 1 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0925X / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium double contrast, Chromaturia, Gastritis, Hydrocele, Intussusception, Irritability, Large intestinal obstruction reduction, Surgery, Vomiting, White blood cell count increased, X-ray abnormal, Enema administration, Ultrasound abdomen abnormal, Explorative laparotomy, Abdominal X-ray

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: PRILOSEC
Current Illness:
Preexisting Conditions: Gastrooesophageal reflux; Omphalitis . PMH: lingual frenulum release
Allergies:
Diagnostic Lab Data: Unknown Labs and diagnostics: Abd US (+) for ileocolic IS. Abd X-ray (+) for SBO. Air enema (+) for IS. WBC 18.1.
CDC 'Split Type': WAES0903USA00374

Write-up: Information has been received from a physician concerning an 18 week old male patient with a history of reflux and umbilical infection when he was born who on 16-SEP-2008 was vaccinated with the first 2 ml po dose of ROTATEQ. On 17-NOV-2008 the patient was vaccinated with the second 2 ml po dose of ROTATEQ (lot # 662618/0925X). Concomitant therapy included PRILOSEC. Subsequently, the patient experienced intussusception and was hospitalized on 20-NOV-2008. On 22-NOV-2008 the patient was diagnosed with intussusception. The physician decided not to administer the third dose of ROTATEQ. Abdominal surgery was performed and was noted by the reporting physician to be an other important medical event. At the time of reporting, the patient had recovered. Additional information has been requested. 3/23/09 MR received for DOS 11/22-24/2008 with D/C DX: Intussusception. pt presented with several week hx of intolerance to feedings. On 11/20/08 became irritable and fussy, had rust colored urine and vomited large amt. Admitted to local hospital for suspected gastritis. Bilateral hydrocele noted in scrotum with concern for SBO. Transfered to current hospital where abd US confirmed IS. Attempted reduction with air enema failed. To OR for ex lap and reduction. Did well post-op and d/c. F/u 12/16/08-recovered.


Changed on 3/2/2010

VAERS ID: 341225 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:Iowa
Vaccinated:2008-11-17
Onset:2008-11-20
Submitted:2009-03-05
Entered:2009-03-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B201BA / 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF515AA / 1 LL / IM
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC C68309 / 1 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0925X / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium double contrast, Chromaturia, Gastritis, Hydrocele, Intussusception, Irritability, Large intestinal obstruction reduction, Surgery, Vomiting, White blood cell count increased, X-ray abnormal, Enema administration, Ultrasound abdomen abnormal, Explorative laparotomy, Abdominal X-ray

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: PRILOSEC
Current Illness:
Preexisting Conditions: Gastrooesophageal reflux; Omphalitis . PMH: lingual frenulum release
Allergies:
Diagnostic Lab Data: Unknown Labs and diagnostics: Abd US (+) for ileocolic IS. Abd X-ray (+) for SBO. Air enema (+) for IS. WBC 18.1.
CDC 'Split Type': WAES0903USA00374

Write-up: Information has been received from a physician concerning an 18 week old male patient with a history of reflux and umbilical infection when he was born who on 16-SEP-2008 was vaccinated with the first 2 ml po dose of ROTATEQ. On 17-NOV-2008 the patient was vaccinated with the second 2 ml po dose of ROTATEQ (lot # 662618/0925X). Concomitant therapy included PRILOSEC. Subsequently, the patient experienced intussusception and was hospitalized on 20-NOV-2008. On 22-NOV-2008 the patient was diagnosed with intussusception. The physician decided not to administer the third dose of ROTATEQ. Abdominal surgery was performed and was noted by the reporting physician to be an other important medical event. At the time of reporting, the patient had recovered. Additional information has been requested. 3/23/09 MR received for DOS 11/22-24/2008 with D/C DX: Intussusception. pt presented with several week hx of intolerance to feedings. On 11/20/08 became irritable and fussy, had rust colored urine and vomited large amt. Admitted to local hospital for suspected gastritis. Bilateral hydrocele noted in scrotum with concern for SBO. Transfered to current hospital where abd US confirmed IS. Attempted reduction with air enema failed. To OR for ex lap and reduction. Did well post-op and d/c. F/u 12/16/08-recovered.


Changed on 4/7/2010

VAERS ID: 341225 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:Iowa
Vaccinated:2008-11-17
Onset:2008-11-20
Submitted:2009-03-05
Entered:2009-03-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B201BA / 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF515AA / 1 LL / IM
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC C68309 / 1 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0925X / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium double contrast, Chromaturia, Gastritis, Hydrocele, Intussusception, Irritability, Large intestinal obstruction reduction, Surgery, Vomiting, White blood cell count increased, X-ray abnormal, Enema administration, Ultrasound abdomen abnormal, Explorative laparotomy, Abdominal X-ray

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: PRILOSEC
Current Illness:
Preexisting Conditions: Gastrooesophageal reflux; Omphalitis . PMH: lingual frenulum release
Allergies:
Diagnostic Lab Data: Unknown Labs and diagnostics: Abd US (+) for ileocolic IS. Abd X-ray (+) for SBO. Air enema (+) for IS. WBC 18.1.
CDC 'Split Type': WAES0903USA00374

Write-up: Information has been received from a physician concerning an 18 week old male patient with a history of reflux and umbilical infection when he was born who on 16-SEP-2008 was vaccinated with the first 2 ml po dose of ROTATEQ. On 17-NOV-2008 the patient was vaccinated with the second 2 ml po dose of ROTATEQ (lot # 662618/0925X). Concomitant therapy included PRILOSEC. Subsequently, the patient experienced intussusception and was hospitalized on 20-NOV-2008. On 22-NOV-2008 the patient was diagnosed with intussusception. The physician decided not to administer the third dose of ROTATEQ. Abdominal surgery was performed and was noted by the reporting physician to be an other important medical event. At the time of reporting, the patient had recovered. Additional information has been requested. 3/23/09 MR received for DOS 11/22-24/2008 with D/C DX: Intussusception. pt presented with several week hx of intolerance to feedings. On 11/20/08 became irritable and fussy, had rust colored urine and vomited large amt. Admitted to local hospital for suspected gastritis. Bilateral hydrocele noted in scrotum with concern for SBO. Transfered to current hospital where abd US confirmed IS. Attempted reduction with air enema failed. To OR for ex lap and reduction. Did well post-op and d/c. F/u 12/16/08-recovered.


Changed on 8/31/2010

VAERS ID: 341225 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:Iowa
Vaccinated:2008-11-17
Onset:2008-11-20
Submitted:2009-03-05
Entered:2009-03-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B201BA / 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF515AA / 1 LL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH C68309 / 1 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0925X / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium double contrast, Chromaturia, Gastritis, Hydrocele, Intussusception, Irritability, Large intestinal obstruction reduction, Surgery, Vomiting, White blood cell count increased, X-ray abnormal, Enema administration, Ultrasound abdomen abnormal, Explorative laparotomy, Abdominal X-ray

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: PRILOSEC
Current Illness:
Preexisting Conditions: Gastrooesophageal reflux; Omphalitis . PMH: lingual frenulum release
Allergies:
Diagnostic Lab Data: Unknown Labs and diagnostics: Abd US (+) for ileocolic IS. Abd X-ray (+) for SBO. Air enema (+) for IS. WBC 18.1.
CDC 'Split Type': WAES0903USA00374

Write-up: Information has been received from a physician concerning an 18 week old male patient with a history of reflux and umbilical infection when he was born who on 16-SEP-2008 was vaccinated with the first 2 ml po dose of ROTATEQ. On 17-NOV-2008 the patient was vaccinated with the second 2 ml po dose of ROTATEQ (lot # 662618/0925X). Concomitant therapy included PRILOSEC. Subsequently, the patient experienced intussusception and was hospitalized on 20-NOV-2008. On 22-NOV-2008 the patient was diagnosed with intussusception. The physician decided not to administer the third dose of ROTATEQ. Abdominal surgery was performed and was noted by the reporting physician to be an other important medical event. At the time of reporting, the patient had recovered. Additional information has been requested. 3/23/09 MR received for DOS 11/22-24/2008 with D/C DX: Intussusception. pt presented with several week hx of intolerance to feedings. On 11/20/08 became irritable and fussy, had rust colored urine and vomited large amt. Admitted to local hospital for suspected gastritis. Bilateral hydrocele noted in scrotum with concern for SBO. Transfered to current hospital where abd US confirmed IS. Attempted reduction with air enema failed. To OR for ex lap and reduction. Did well post-op and d/c. F/u 12/16/08-recovered.


Changed on 5/13/2013

VAERS ID: 341225 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:Iowa
Vaccinated:2008-11-17
Onset:2008-11-20
Submitted:2009-03-05
Entered:2009-03-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B201BA / 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF515AA / 1 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH C68309 / 1 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0925X / 1 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0925X / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium double contrast, Chromaturia, Gastritis, Hydrocele, Intussusception, Irritability, Large intestinal obstruction reduction, Surgery, Vomiting, White blood cell count increased, X-ray abnormal, Enema administration, Ultrasound abdomen abnormal, Explorative laparotomy, Abdominal X-ray

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: PRILOSEC
Current Illness:
Preexisting Conditions: Gastrooesophageal reflux; Omphalitis . PMH: lingual frenulum release
Allergies:
Diagnostic Lab Data: Unknown Labs and diagnostics: Abd US (+) for ileocolic IS. Abd X-ray (+) for SBO. Air enema (+) for IS. WBC 18.1.
CDC 'Split Type': WAES0903USA00374

Write-up: Information has been received from a physician concerning an 18 week old male patient with a history of reflux and umbilical infection when he was born who on 16-SEP-2008 was vaccinated with the first 2 ml po dose of ROTATEQ. On 17-NOV-2008 the patient was vaccinated with the second 2 ml po dose of ROTATEQ (lot # 662618/0925X). Concomitant therapy included PRILOSEC. Subsequently, the patient experienced intussusception and was hospitalized on 20-NOV-2008. On 22-NOV-2008 the patient was diagnosed with intussusception. The physician decided not to administer the third dose of ROTATEQ. Abdominal surgery was performed and was noted by the reporting physician to be an other important medical event. At the time of reporting, the patient had recovered. Additional information has been requested. 3/23/09 MR received for DOS 11/22-24/2008 with D/C DX: Intussusception. pt presented with several week hx of intolerance to feedings. On 11/20/08 became irritable and fussy, had rust colored urine and vomited large amt. Admitted to local hospital for suspected gastritis. Bilateral hydrocele noted in scrotum with concern for SBO. Transfered to current hospital where abd US confirmed IS. Attempted reduction with air enema failed. To OR for ex lap and reduction. Did well post-op and d/c. F/u 12/16/08-recovered.


Changed on 4/14/2017

VAERS ID: 341225 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:Iowa
Vaccinated:2008-11-17
Onset:2008-11-20
Submitted:2009-03-05
Entered:2009-03-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B201BA / 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF515AA / 1 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH C68309 / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0925X / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium double contrast, Chromaturia, Gastritis, Hydrocele, Intussusception, Irritability, Large intestinal obstruction reduction, Surgery, Vomiting, White blood cell count increased, X-ray abnormal, Enema administration, Ultrasound abdomen abnormal, Explorative laparotomy, Abdominal X-ray

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: PRILOSEC
Current Illness:
Preexisting Conditions: Gastrooesophageal reflux; Omphalitis . PMH: lingual frenulum release
Allergies:
Diagnostic Lab Data: Unknown Labs and diagnostics: Abd US (+) for ileocolic IS. Abd X-ray (+) for SBO. Air enema (+) for IS. WBC 18.1.
CDC 'Split Type': WAES0903USA00374

Write-up: Information has been received from a physician concerning an 18 week old male patient with a history of reflux and umbilical infection when he was born who on 16-SEP-2008 was vaccinated with the first 2 ml po dose of ROTATEQ. On 17-NOV-2008 the patient was vaccinated with the second 2 ml po dose of ROTATEQ (lot # 662618/0925X). Concomitant therapy included PRILOSEC. Subsequently, the patient experienced intussusception and was hospitalized on 20-NOV-2008. On 22-NOV-2008 the patient was diagnosed with intussusception. The physician decided not to administer the third dose of ROTATEQ. Abdominal surgery was performed and was noted by the reporting physician to be an other important medical event. At the time of reporting, the patient had recovered. Additional information has been requested. 3/23/09 MR received for DOS 11/22-24/2008 with D/C DX: Intussusception. pt presented with several week hx of intolerance to feedings. On 11/20/08 became irritable and fussy, had rust colored urine and vomited large amt. Admitted to local hospital for suspected gastritis. Bilateral hydrocele noted in scrotum with concern for SBO. Transfered to current hospital where abd US confirmed IS. Attempted reduction with air enema failed. To OR for ex lap and reduction. Did well post-op and d/c. F/u 12/16/08-recovered.


Changed on 9/14/2017

VAERS ID: 341225 Before After
VAERS Form:(blank) 1
Age:0.3
Sex:Male
Location:Iowa
Vaccinated:2008-11-17
Onset:2008-11-20
Submitted:2009-03-05
Entered:2009-03-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B201BA / 1 2 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF515AA / 1 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH C68309 / 1 2 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0925X / 1 2 - MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Intussusception, Surgery

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: PRILOSEC
Current Illness:
Preexisting Conditions: Gastrooesophageal reflux; Omphalitis . PMH: lingual frenulum release
Allergies:
Diagnostic Lab Data: Unknown Labs and diagnostics: Abd US (+) for ileocolic IS. Abd X-ray (+) for SBO. Air enema (+) for IS. WBC 18.1.
CDC 'Split Type': WAES0903USA00374

Write-up: Information has been received from a physician concerning an 18 week old male patient with a history of reflux and umbilical infection when he was born who on 16-SEP-2008 was vaccinated with the first 2 ml po dose of ROTATEQ. On 17-NOV-2008 the patient was vaccinated with the second 2 ml po dose of ROTATEQ (lot # 662618/0925X). Concomitant therapy included PRILOSEC. Subsequently, the patient experienced intussusception and was hospitalized on 20-NOV-2008. On 22-NOV-2008 the patient was diagnosed with intussusception. The physician decided not to administer the third dose of ROTATEQ. Abdominal surgery was performed and was noted by the reporting physician to be an other important medical event. At the time of reporting, the patient had recovered. Additional information has been requested. 3/23/09 MR received for DOS 11/22-24/2008 with D/C DX: Intussusception. pt presented with several week hx of intolerance to feedings. On 11/20/08 became irritable and fussy, had rust colored urine and vomited large amt. Admitted to local hospital for suspected gastritis. Bilateral hydrocele noted in scrotum with concern for SBO. Transfered to current hospital where abd US confirmed IS. Attempted reduction with air enema failed. To OR for ex lap and reduction. Did well post-op and d/c. F/u 12/16/08-recovered.


Changed on 2/14/2018

VAERS ID: 341225 Before After
VAERS Form:1
Age:0.3
Sex:Male
Location:Iowa
Vaccinated:2008-11-17
Onset:2008-11-20
Submitted:2009-03-05
Entered:2009-03-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B201BA / 2 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF515AA / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH C68309 / 2 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0925X / 2 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Intussusception, Surgery

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: PRILOSEC
Current Illness:
Preexisting Conditions: Gastrooesophageal reflux; Omphalitis . PMH: lingual frenulum release
Allergies:
Diagnostic Lab Data: Unknown Labs and diagnostics: Abd US (+) for ileocolic IS. Abd X-ray (+) for SBO. Air enema (+) for IS. WBC 18.1.
CDC 'Split Type': WAES0903USA00374

Write-up: Information has been received from a physician concerning an 18 week old male patient with a history of reflux and umbilical infection when he was born who on 16-SEP-2008 was vaccinated with the first 2 ml po dose of ROTATEQ. On 17-NOV-2008 the patient was vaccinated with the second 2 ml po dose of ROTATEQ (lot # 662618/0925X). Concomitant therapy included PRILOSEC. Subsequently, the patient experienced intussusception and was hospitalized on 20-NOV-2008. On 22-NOV-2008 the patient was diagnosed with intussusception. The physician decided not to administer the third dose of ROTATEQ. Abdominal surgery was performed and was noted by the reporting physician to be an other important medical event. At the time of reporting, the patient had recovered. Additional information has been requested. 3/23/09 MR received for DOS 11/22-24/2008 with D/C DX: Intussusception. pt presented with several week hx of intolerance to feedings. On 11/20/08 became irritable and fussy, had rust colored urine and vomited large amt. Admitted to local hospital for suspected gastritis. Bilateral hydrocele noted in scrotum with concern for SBO. Transfered to current hospital where abd US confirmed IS. Attempted reduction with air enema failed. To OR for ex lap and reduction. Did well post-op and d/c. F/u 12/16/08-recovered.


Changed on 6/14/2018

VAERS ID: 341225 Before After
VAERS Form:1
Age:0.3
Sex:Male
Location:Iowa
Vaccinated:2008-11-17
Onset:2008-11-20
Submitted:2009-03-05
Entered:2009-03-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B201BA / 2 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF515AA / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH C68309 / 2 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0925X / 2 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Intussusception, Surgery

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: PRILOSEC
Current Illness:
Preexisting Conditions: Gastrooesophageal reflux; Omphalitis . PMH: lingual frenulum release
Allergies:
Diagnostic Lab Data: Unknown Labs and diagnostics: Abd US (+) for ileocolic IS. Abd X-ray (+) for SBO. Air enema (+) for IS. WBC 18.1.
CDC 'Split Type': WAES0903USA00374

Write-up: Information has been received from a physician concerning an 18 week old male patient with a history of reflux and umbilical infection when he was born who on 16-SEP-2008 was vaccinated with the first 2 ml po dose of ROTATEQ. On 17-NOV-2008 the patient was vaccinated with the second 2 ml po dose of ROTATEQ (lot # 662618/0925X). Concomitant therapy included PRILOSEC. Subsequently, the patient experienced intussusception and was hospitalized on 20-NOV-2008. On 22-NOV-2008 the patient was diagnosed with intussusception. The physician decided not to administer the third dose of ROTATEQ. Abdominal surgery was performed and was noted by the reporting physician to be an other important medical event. At the time of reporting, the patient had recovered. Additional information has been requested. 3/23/09 MR received for DOS 11/22-24/2008 with D/C DX: Intussusception. pt presented with several week hx of intolerance to feedings. On 11/20/08 became irritable and fussy, had rust colored urine and vomited large amt. Admitted to local hospital for suspected gastritis. Bilateral hydrocele noted in scrotum with concern for SBO. Transfered to current hospital where abd US confirmed IS. Attempted reduction with air enema failed. To OR for ex lap and reduction. Did well post-op and d/c. F/u 12/16/08-recovered.


Changed on 8/14/2018

VAERS ID: 341225 Before After
VAERS Form:1
Age:0.3
Sex:Male
Location:Iowa
Vaccinated:2008-11-17
Onset:2008-11-20
Submitted:2009-03-05
Entered:2009-03-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B201BA / 2 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF515AA / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH C68309 / 2 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0925X / 2 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Intussusception, Surgery

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: PRILOSEC
Current Illness:
Preexisting Conditions: Gastrooesophageal reflux; Omphalitis . PMH: lingual frenulum release
Allergies:
Diagnostic Lab Data: Unknown Labs and diagnostics: Abd US (+) for ileocolic IS. Abd X-ray (+) for SBO. Air enema (+) for IS. WBC 18.1.
CDC 'Split Type': WAES0903USA00374

Write-up: Information has been received from a physician concerning an 18 week old male patient with a history of reflux and umbilical infection when he was born who on 16-SEP-2008 was vaccinated with the first 2 ml po dose of ROTATEQ. On 17-NOV-2008 the patient was vaccinated with the second 2 ml po dose of ROTATEQ (lot # 662618/0925X). Concomitant therapy included PRILOSEC. Subsequently, the patient experienced intussusception and was hospitalized on 20-NOV-2008. On 22-NOV-2008 the patient was diagnosed with intussusception. The physician decided not to administer the third dose of ROTATEQ. Abdominal surgery was performed and was noted by the reporting physician to be an other important medical event. At the time of reporting, the patient had recovered. Additional information has been requested. 3/23/09 MR received for DOS 11/22-24/2008 with D/C DX: Intussusception. pt presented with several week hx of intolerance to feedings. On 11/20/08 became irritable and fussy, had rust colored urine and vomited large amt. Admitted to local hospital for suspected gastritis. Bilateral hydrocele noted in scrotum with concern for SBO. Transfered to current hospital where abd US confirmed IS. Attempted reduction with air enema failed. To OR for ex lap and reduction. Did well post-op and d/c. F/u 12/16/08-recovered.


Changed on 9/14/2018

VAERS ID: 341225 Before After
VAERS Form:1
Age:0.3
Sex:Male
Location:Iowa
Vaccinated:2008-11-17
Onset:2008-11-20
Submitted:2009-03-05
Entered:2009-03-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B201BA / 2 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF515AA / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH C68309 / 2 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0925X / 2 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Intussusception, Surgery

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: PRILOSEC
Current Illness:
Preexisting Conditions: Gastrooesophageal reflux; Omphalitis . PMH: lingual frenulum release
Allergies:
Diagnostic Lab Data: Unknown Labs and diagnostics: Abd US (+) for ileocolic IS. Abd X-ray (+) for SBO. Air enema (+) for IS. WBC 18.1.
CDC 'Split Type': WAES0903USA00374

Write-up: Information has been received from a physician concerning an 18 week old male patient with a history of reflux and umbilical infection when he was born who on 16-SEP-2008 was vaccinated with the first 2 ml po dose of ROTATEQ. On 17-NOV-2008 the patient was vaccinated with the second 2 ml po dose of ROTATEQ (lot # 662618/0925X). Concomitant therapy included PRILOSEC. Subsequently, the patient experienced intussusception and was hospitalized on 20-NOV-2008. On 22-NOV-2008 the patient was diagnosed with intussusception. The physician decided not to administer the third dose of ROTATEQ. Abdominal surgery was performed and was noted by the reporting physician to be an other important medical event. At the time of reporting, the patient had recovered. Additional information has been requested. 3/23/09 MR received for DOS 11/22-24/2008 with D/C DX: Intussusception. pt presented with several week hx of intolerance to feedings. On 11/20/08 became irritable and fussy, had rust colored urine and vomited large amt. Admitted to local hospital for suspected gastritis. Bilateral hydrocele noted in scrotum with concern for SBO. Transfered to current hospital where abd US confirmed IS. Attempted reduction with air enema failed. To OR for ex lap and reduction. Did well post-op and d/c. F/u 12/16/08-recovered.


Changed on 10/14/2018

VAERS ID: 341225 Before After
VAERS Form:1
Age:0.3
Sex:Male
Location:Iowa
Vaccinated:2008-11-17
Onset:2008-11-20
Submitted:2009-03-05
Entered:2009-03-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B201BA / 2 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF515AA / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH C68309 / 2 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0925X / 2 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Intussusception, Surgery

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: PRILOSEC
Current Illness:
Preexisting Conditions: Gastrooesophageal reflux; Omphalitis . PMH: lingual frenulum release
Allergies:
Diagnostic Lab Data: Unknown Labs and diagnostics: Abd US (+) for ileocolic IS. Abd X-ray (+) for SBO. Air enema (+) for IS. WBC 18.1.
CDC 'Split Type': WAES0903USA00374

Write-up: Information has been received from a physician concerning an 18 week old male patient with a history of reflux and umbilical infection when he was born who on 16-SEP-2008 was vaccinated with the first 2 ml po dose of ROTATEQ. On 17-NOV-2008 the patient was vaccinated with the second 2 ml po dose of ROTATEQ (lot # 662618/0925X). Concomitant therapy included PRILOSEC. Subsequently, the patient experienced intussusception and was hospitalized on 20-NOV-2008. On 22-NOV-2008 the patient was diagnosed with intussusception. The physician decided not to administer the third dose of ROTATEQ. Abdominal surgery was performed and was noted by the reporting physician to be an other important medical event. At the time of reporting, the patient had recovered. Additional information has been requested. 3/23/09 MR received for DOS 11/22-24/2008 with D/C DX: Intussusception. pt presented with several week hx of intolerance to feedings. On 11/20/08 became irritable and fussy, had rust colored urine and vomited large amt. Admitted to local hospital for suspected gastritis. Bilateral hydrocele noted in scrotum with concern for SBO. Transfered to current hospital where abd US confirmed IS. Attempted reduction with air enema failed. To OR for ex lap and reduction. Did well post-op and d/c. F/u 12/16/08-recovered.

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