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This is VAERS ID 361353

History of Changes from the VAERS Wayback Machine

First Appeared on 12/8/2009

VAERS ID: 361353
VAERS Form:
Age:9.0
Gender:Female
Location:California
Vaccinated:2009-10-08
Onset:2009-10-14
Submitted:2009-10-16
Entered:2009-10-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U3203AA / 2 LA / IM
FLUN(H1N1): INFLUENZA (H1N1) (INFLUENZA A (H1N1) 2009 MONOVALENT, INTRANASAL SPRAY) / MEDIMMUNE VACCINES, INC. 500751P / 0 - / IN

Administered by: Private      Purchased by: Unknown
Symptoms: Apnoea, Blood albumin decreased, Blood alkaline phosphatase, Blood calcium decreased, Blood glucose increased, Bronchopneumonia, Cardiac arrest, Chills, Death, Electrocardiogram abnormal, Eosinophil count decreased, Haematocrit decreased, Haemoglobin decreased, Influenza, Leukopenia, Lividity, Lung consolidation, Monocyte count decreased, Mydriasis, Neutrophil count decreased, Pallor, Platelet count normal, Pneumonia pneumococcal, Pulse absent, Pupil fixed, Red blood cell count decreased, Resuscitation, Trisomy 21, White blood cell count decreased, Drug screen positive, Red blood cell sedimentation rate increased, Red cell distribution width increased, Bacterial test positive, Diffuse alveolar damage, Leukaemia in remission, Streptococcus identification test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2009-10-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: Limping
Preexisting Conditions: H/O Leukemia 2002; Down''s Syndrome. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Down Syndrome. Cough, fever. Frequent colds. Discharge from eyes. Vomiting and diarrhea. Lymphadenopathy. Foot pain. CBC abnormal.
Allergies:
Diagnostic Lab Data: CBC: 2.5, 7.5, 21.3, 207; Sed rate 125. 10/20/09 ER records received service date 10/14/09. LABS and Diagnostics: EEG - Asystole. CHEM - Glucose 107 mg/dL (H) Calcium 3.5 mg/dL (L) Albumin 3.4 g/dL (L) Alk Phos 170 U/L (L). CBC - WBC 2.5
CDC 'Split Type':

Write-up: None Stated. On 10/19/09, the PCP stated that coroner called him and told him that he found consolidation of the lungs on autopsy. Autopsy report is not complete yet. 10/20/09 ER records received service date 10/14/09. Assessment: Cardiac arrest. CPR initiated. Pupils fixed and dilated. Apnea, pale. Rigor, lividity. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Assessment: Death. Office staff unable to contact patient''s family, eventually visited patient''s home. learnd that patient was found dead at home and taken to ER. 11/3/09 Additional ER records received for service date 10/14/09. Found supine on floor at home apneic and pulseless. Cardiac arrest. CPR initiated. 12/8/09 Autopsy received. Pronounced dead on 10/13/2009 Final cause of death: Pneumococcal Pneumonia. Pandemic Influenza A. Additional Information Abstracted: Other contributing conditions - Leukopenia, history of leukemia, Down syndrome. Drug Screen Heart Blood: Dextromethorphan <0.10 ug/ml, Promethazine 0.11 ug/ml. /ksk 12/28/09 Pathology report received. Receipt date 10/23/2009. Sign out date 12/21/2009. Diagnosis: Lung - Diffuse alveolar damage and bronchopneumonia. Immunohistochemical and molecular evidence of novel influenza A H1N1. Immunohistochemical and molecular evidence of Streptococcus pneumoniae. Immunohistochemical evidence of Neisseria meningitidis without molecular confirmation. No immunohistochemical evidence of Group A Streptococcus or Haemophilus influenzae.


Changed on 3/2/2010

VAERS ID: 361353 Before After
VAERS Form:
Age:9.0
Gender:Female
Location:California
Vaccinated:2009-10-08
Onset:2009-10-14
Submitted:2009-10-16
Entered:2009-10-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U3203AA / 2 LA / IM
FLUN(H1N1): INFLUENZA (H1N1) (INFLUENZA A (H1N1) 2009 MONOVALENT, INTRANASAL SPRAY) / MEDIMMUNE VACCINES, INC. 500751P / 0 - / IN

Administered by: Private      Purchased by: Unknown
Symptoms: Apnoea, Blood albumin decreased, Blood alkaline phosphatase, Blood calcium decreased, Blood glucose increased, Bronchopneumonia, Cardiac arrest, Chills, Death, Electrocardiogram abnormal, Eosinophil count decreased, Haematocrit decreased, Haemoglobin decreased, Influenza, Leukopenia, Lividity, Lung consolidation, Monocyte count decreased, Mydriasis, Neutrophil count decreased, Pallor, Platelet count normal, Pneumonia pneumococcal, Pulse absent, Pupil fixed, Red blood cell count decreased, Resuscitation, Trisomy 21, White blood cell count decreased, Drug screen positive, Red blood cell sedimentation rate increased, Red cell distribution width increased, Bacterial test positive, Diffuse alveolar damage, Leukaemia in remission, Streptococcus identification test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2009-10-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: Limping
Preexisting Conditions: H/O Leukemia 2002; Down''s Syndrome. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Down Syndrome. Cough, fever. Frequent colds. Discharge from eyes. Vomiting and diarrhea. Lymphadenopathy. Foot pain. CBC abnormal.
Allergies:
Diagnostic Lab Data: CBC: 2.5, 7.5, 21.3, 207; Sed rate 125. 10/20/09 ER records received service date 10/14/09. LABS and Diagnostics: EEG - Asystole. CHEM - Glucose 107 mg/dL (H) Calcium 3.5 mg/dL (L) Albumin 3.4 g/dL (L) Alk Phos 170 U/L (L). CBC - WBC 2.5
CDC 'Split Type':

Write-up: None Stated. On 10/19/09, the PCP stated that coroner called him and told him that he found consolidation of the lungs on autopsy. Autopsy report is not complete yet. 10/20/09 ER records received service date 10/14/09. Assessment: Cardiac arrest. CPR initiated. Pupils fixed and dilated. Apnea, pale. Rigor, lividity. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Assessment: Death. Office staff unable to contact patient''s family, eventually visited patient''s home. learnd that patient was found dead at home and taken to ER. 11/3/09 Additional ER records received for service date 10/14/09. Found supine on floor at home apneic and pulseless. Cardiac arrest. CPR initiated. 12/8/09 Autopsy received. Pronounced dead on 10/13/2009 Final cause of death: Pneumococcal Pneumonia. Pandemic Influenza A. Additional Information Abstracted: Other contributing conditions - Leukopenia, history of leukemia, Down syndrome. Drug Screen Heart Blood: Dextromethorphan <0.10 ug/ml, Promethazine 0.11 ug/ml. /ksk 12/28/09 Pathology report received. Receipt date 10/23/2009. Sign out date 12/21/2009. Diagnosis: Lung - Diffuse alveolar damage and bronchopneumonia. Immunohistochemical and molecular evidence of novel influenza A H1N1. Immunohistochemical and molecular evidence of Streptococcus pneumoniae. Immunohistochemical evidence of Neisseria meningitidis without molecular confirmation. No immunohistochemical evidence of Group A Streptococcus or Haemophilus influenzae.


Changed on 4/7/2010

VAERS ID: 361353 Before After
VAERS Form:
Age:9.0
Gender:Female
Location:California
Vaccinated:2009-10-08
Onset:2009-10-14
Submitted:2009-10-16
Entered:2009-10-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U3203AA / 2 LA / IM
FLUN(H1N1): INFLUENZA (H1N1) (INFLUENZA A (H1N1) 2009 MONOVALENT, INTRANASAL SPRAY) / MEDIMMUNE VACCINES, INC. 500751P / 0 - / IN

Administered by: Private      Purchased by: Unknown
Symptoms: Death, Full blood count abnormal, Haematocrit decreased, Haemoglobin decreased, Platelet count normal, White blood cell count decreased, Red blood cell sedimentation rate increased

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2009-10-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: Limping
Preexisting Conditions: H/O Leukemia 2002; Down''s Syndrome. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Down Syndrome. Cough, fever. Frequent colds. Discharge from eyes. Vomiting and diarrhea. Lymphadenopathy. Foot pain. CBC abnormal.
Allergies:
Diagnostic Lab Data: CBC: 2.5, 7.5, 21.3, 207; Sed rate 125. 10/20/09 ER records received service date 10/14/09. LABS and Diagnostics: EEG - Asystole. CHEM - Glucose 107 mg/dL (H) Calcium 3.5 mg/dL (L) Albumin 3.4 g/dL (L) Alk Phos 170 U/L (L). CBC - WBC 2.5
CDC 'Split Type':

Write-up: None Stated. On 10/19/09, the PCP stated that coroner called him and told him that he found consolidation of the lungs on autopsy. Autopsy report is not complete yet. 10/20/09 ER records received service date 10/14/09. Assessment: Cardiac arrest. CPR initiated. Pupils fixed and dilated. Apnea, pale. Rigor, lividity. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Assessment: Death. Office staff unable to contact patient''s family, eventually visited patient''s home. learnd that patient was found dead at home and taken to ER. 11/3/09 Additional ER records received for service date 10/14/09. Found supine on floor at home apneic and pulseless. Cardiac arrest. CPR initiated. 12/8/09 Autopsy received. Pronounced dead on 10/13/2009 Final cause of death: Pneumococcal Pneumonia. Pandemic Influenza A. Additional Information Abstracted: Other contributing conditions - Leukopenia, history of leukemia, Down syndrome. Drug Screen Heart Blood: Dextromethorphan <0.10 ug/ml, Promethazine 0.11 ug/ml. /ksk 12/28/09 Pathology report received. Receipt date 10/23/2009. Sign out date 12/21/2009. Diagnosis: Lung - Diffuse alveolar damage and bronchopneumonia. Immunohistochemical and molecular evidence of novel influenza A H1N1. Immunohistochemical and molecular evidence of Streptococcus pneumoniae. Immunohistochemical evidence of Neisseria meningitidis without molecular confirmation. No immunohistochemical evidence of Group A Streptococcus or Haemophilus influenzae. All follow-up attempts have been completed per company SOPs. No further information available.


Changed on 6/2/2010

VAERS ID: 361353 Before After
VAERS Form:
Age:9.0
Gender:Female
Location:California
Vaccinated:2009-10-08
Onset:2009-10-14
Submitted:2009-10-16
Entered:2009-10-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U3203AA / 2 LA / IM
FLUN(H1N1): INFLUENZA (H1N1) (INFLUENZA A (H1N1) 2009 MONOVALENT, INTRANASAL SPRAY) INFLUENZA (H1N1) (H1N1 (MONOVALENT) (MEDIMMUNE)) / MEDIMMUNE VACCINES, INC. 500751P / 0 - / IN

Administered by: Private      Purchased by: Unknown
Symptoms: Death, Full blood count abnormal, Haematocrit decreased, Haemoglobin decreased, Red blood cell sedimentation rate increased

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2009-10-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: Limping
Preexisting Conditions: H/O Leukemia 2002; Down''s Syndrome. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Down Syndrome. Cough, fever. Frequent colds. Discharge from eyes. Vomiting and diarrhea. Lymphadenopathy. Foot pain. CBC abnormal.
Allergies:
Diagnostic Lab Data: CBC: 2.5, 7.5, 21.3, 207; Sed rate 125. 10/20/09 ER records received service date 10/14/09. LABS and Diagnostics: EEG - Asystole. CHEM - Glucose 107 mg/dL (H) Calcium 3.5 mg/dL (L) Albumin 3.4 g/dL (L) Alk Phos 170 U/L (L). CBC - WBC 2.5
CDC 'Split Type':

Write-up: None Stated. On 10/19/09, the PCP stated that coroner called him and told him that he found consolidation of the lungs on autopsy. Autopsy report is not complete yet. 10/20/09 ER records received service date 10/14/09. Assessment: Cardiac arrest. CPR initiated. Pupils fixed and dilated. Apnea, pale. Rigor, lividity. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Assessment: Death. Office staff unable to contact patient''s family, eventually visited patient''s home. learnd that patient was found dead at home and taken to ER. 11/3/09 Additional ER records received for service date 10/14/09. Found supine on floor at home apneic and pulseless. Cardiac arrest. CPR initiated. 12/8/09 Autopsy received. Pronounced dead on 10/13/2009 Final cause of death: Pneumococcal Pneumonia. Pandemic Influenza A. Additional Information Abstracted: Other contributing conditions - Leukopenia, history of leukemia, Down syndrome. Drug Screen Heart Blood: Dextromethorphan <0.10 ug/ml, Promethazine 0.11 ug/ml. /ksk 12/28/09 Pathology report received. Receipt date 10/23/2009. Sign out date 12/21/2009. Diagnosis: Lung - Diffuse alveolar damage and bronchopneumonia. Immunohistochemical and molecular evidence of novel influenza A H1N1. Immunohistochemical and molecular evidence of Streptococcus pneumoniae. Immunohistochemical evidence of Neisseria meningitidis without molecular confirmation. No immunohistochemical evidence of Group A Streptococcus or Haemophilus influenzae. All follow-up attempts have been completed per company SOPs. No further information available.


Changed on 7/31/2010

VAERS ID: 361353 Before After
VAERS Form:
Age:9.0
Gender:Female
Location:California
Vaccinated:2009-10-08
Onset:2009-10-14
Submitted:2009-10-16
Entered:2009-10-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U3203AA / 2 LA / IM
FLUN(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) (MEDIMMUNE)) / MEDIMMUNE VACCINES, INC. 500751P / 0 - / IN

Administered by: Private      Purchased by: Unknown
Symptoms: Blood alkaline phosphatase normal, Blood glucose normal, Death, Full blood count abnormal, Haematocrit decreased, Haemoglobin decreased, Pupil fixed, Red blood cell sedimentation rate increased, Immunohistochemistry, Neisseria test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2009-10-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: Limping
Preexisting Conditions: H/O Leukemia 2002; Down''s Syndrome. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Down Syndrome. Cough, fever. Frequent colds. Discharge from eyes. Vomiting and diarrhea. Lymphadenopathy. Foot pain. CBC abnormal.
Allergies:
Diagnostic Lab Data: CBC: 2.5, 7.5, 21.3, 207; Sed rate 125. 10/20/09 ER records received service date 10/14/09. LABS and Diagnostics: EEG - Asystole. CHEM - Glucose 107 mg/dL (H) Calcium 3.5 mg/dL (L) Albumin 3.4 g/dL (L) Alk Phos 170 U/L (L). CBC - WBC 2.5
CDC 'Split Type':

Write-up: None Stated. On 10/19/09, the PCP stated that coroner called him and told him that he found consolidation of the lungs on autopsy. Autopsy report is not complete yet. 10/20/09 ER records received service date 10/14/09. Assessment: Cardiac arrest. CPR initiated. Pupils fixed and dilated. Apnea, pale. Rigor, lividity. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Assessment: Death. Office staff unable to contact patient''s family, eventually visited patient''s home. learnd that patient was found dead at home and taken to ER. 11/3/09 Additional ER records received for service date 10/14/09. Found supine on floor at home apneic and pulseless. Cardiac arrest. CPR initiated. 12/8/09 Autopsy received. Pronounced dead on 10/13/2009 Final cause of death: Pneumococcal Pneumonia. Pandemic Influenza A. Additional Information Abstracted: Other contributing conditions - Leukopenia, history of leukemia, Down syndrome. Drug Screen Heart Blood: Dextromethorphan <0.10 ug/ml, Promethazine 0.11 ug/ml. /ksk 12/28/09 Pathology report received. Receipt date 10/23/2009. Sign out date 12/21/2009. Diagnosis: Lung - Diffuse alveolar damage and bronchopneumonia. Immunohistochemical and molecular evidence of novel influenza A H1N1. Immunohistochemical and molecular evidence of Streptococcus pneumoniae. Immunohistochemical evidence of Neisseria meningitidis without molecular confirmation. No immunohistochemical evidence of Group A Streptococcus or Haemophilus influenzae. All follow-up attempts have been completed per company SOPs. No further information available.


Changed on 8/31/2010

VAERS ID: 361353 Before After
VAERS Form:
Age:9.0
Gender:Female
Location:California
Vaccinated:2009-10-08
Onset:2009-10-14
Submitted:2009-10-16
Entered:2009-10-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U3203AA / 2 LA / IM
FLUN(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) (MEDIMMUNE)) / MEDIMMUNE VACCINES, INC. 500751P / 0 - / IN

Administered by: Private      Purchased by: Unknown
Symptoms: Blood alkaline phosphatase normal, Blood glucose normal, Death, Full blood count abnormal, Haematocrit decreased, Haemoglobin decreased, Platelet count normal, Pupil fixed, White blood cell count decreased, Red blood cell sedimentation rate increased, Immunohistochemistry, Neisseria test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2009-10-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: Limping
Preexisting Conditions: H/O Leukemia 2002; Down''s Syndrome. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Down Syndrome. Cough, fever. Frequent colds. Discharge from eyes. Vomiting and diarrhea. Lymphadenopathy. Foot pain. CBC abnormal.
Allergies:
Diagnostic Lab Data: CBC: 2.5, 7.5, 21.3, 207; Sed rate 125. 10/20/09 ER records received service date 10/14/09. LABS and Diagnostics: EEG - Asystole. CHEM - Glucose 107 mg/dL (H) Calcium 3.5 mg/dL (L) Albumin 3.4 g/dL (L) Alk Phos 170 U/L (L). CBC - WBC 2.5
CDC 'Split Type':

Write-up: None Stated. On 10/19/09, the PCP stated that coroner called him and told him that he found consolidation of the lungs on autopsy. Autopsy report is not complete yet. 10/20/09 ER records received service date 10/14/09. Assessment: Cardiac arrest. CPR initiated. Pupils fixed and dilated. Apnea, pale. Rigor, lividity. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Assessment: Death. Office staff unable to contact patient''s family, eventually visited patient''s home. learnd that patient was found dead at home and taken to ER. 11/3/09 Additional ER records received for service date 10/14/09. Found supine on floor at home apneic and pulseless. Cardiac arrest. CPR initiated. 12/8/09 Autopsy received. Pronounced dead on 10/13/2009 Final cause of death: Pneumococcal Pneumonia. Pandemic Influenza A. Additional Information Abstracted: Other contributing conditions - Leukopenia, history of leukemia, Down syndrome. Drug Screen Heart Blood: Dextromethorphan <0.10 ug/ml, Promethazine 0.11 ug/ml. /ksk 12/28/09 Pathology report received. Receipt date 10/23/2009. Sign out date 12/21/2009. Diagnosis: Lung - Diffuse alveolar damage and bronchopneumonia. Immunohistochemical and molecular evidence of novel influenza A H1N1. Immunohistochemical and molecular evidence of Streptococcus pneumoniae. Immunohistochemical evidence of Neisseria meningitidis without molecular confirmation. No immunohistochemical evidence of Group A Streptococcus or Haemophilus influenzae. All follow-up attempts have been completed per company SOPs. No further information available.


Changed on 1/4/2011

VAERS ID: 361353 Before After
VAERS Form:
Age:9.0
Gender:Female
Location:California
Vaccinated:2009-10-08
Onset:2009-10-14
Submitted:2009-10-16
Entered:2009-10-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U3203AA / 2 LA / IM
FLUN(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) (MEDIMMUNE)) / MEDIMMUNE VACCINES, INC. 500751P / 0 - / IN

Administered by: Private      Purchased by: Unknown
Symptoms: Blood alkaline phosphatase normal, Blood glucose normal, Death, Full blood count abnormal, Haematocrit decreased, Haemoglobin decreased, Platelet count normal, Pupil fixed, White blood cell count decreased, Red blood cell sedimentation rate increased, Immunohistochemistry, Neisseria test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2009-10-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: Limping
Preexisting Conditions: H/O Leukemia 2002; Down''s Syndrome. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Down Syndrome. Cough, fever. Frequent colds. Discharge from eyes. Vomiting and diarrhea. Lymphadenopathy. Foot pain. CBC abnormal.
Allergies:
Diagnostic Lab Data: CBC: 2.5, 7.5, 21.3, 207; Sed rate 125. 10/20/09 ER records received service date 10/14/09. LABS and Diagnostics: EEG - Asystole. CHEM - Glucose 107 mg/dL (H) Calcium 3.5 mg/dL (L) Albumin 3.4 g/dL (L) Alk Phos 170 U/L (L). CBC - WBC 2.5 Thou/uL (L) RBC 2.57 Mill/uL (L) HGB 7.5 g/dL (L) HCT 27.3% (L) RDW 16.4% (H) Neut ABS 565 cells/uL (L) Mono ABS 33 cells/uL (L) Eosin 3 cells/uL (L)
CDC 'Split Type':

Write-up: None Stated. On 10/19/09, the PCP stated that coroner called him and told him that he found consolidation of the lungs on autopsy. Autopsy report is not complete yet. 10/20/09 ER records received service date 10/14/09. Assessment: Cardiac arrest. CPR initiated. Pupils fixed and dilated. Apnea, pale. Rigor, lividity. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Assessment: Death. Office staff unable to contact patient''s family, eventually visited patient''s home. learnd that patient was found dead at home and taken to ER. 11/3/09 Additional ER records received for service date 10/14/09. Found supine on floor at home apneic and pulseless. Cardiac arrest. CPR initiated. 12/8/09 Autopsy received. Pronounced dead on 10/13/2009 Final cause of death: Pneumococcal Pneumonia. Pandemic Influenza A. Additional Information Abstracted: Other contributing conditions - Leukopenia, history of leukemia, Down syndrome. Drug Screen Heart Blood: Dextromethorphan <0.10 ug/ml, Promethazine 0.11 ug/ml. /ksk 12/28/09 Pathology report received. Receipt date 10/23/2009. Sign out date 12/21/2009. Diagnosis: Lung - Diffuse alveolar damage and bronchopneumonia. Immunohistochemical and molecular evidence of novel influenza A H1N1. Immunohistochemical and molecular evidence of Streptococcus pneumoniae. Immunohistochemical evidence of Neisseria meningitidis without molecular confirmation. No immunohistochemical evidence of Group A Streptococcus or Haemophilus influenzae. All follow-up attempts have been completed per company SOPs. No further information available.


Changed on 4/13/2011

VAERS ID: 361353 Before After
VAERS Form:
Age:9.0
Gender:Female
Location:California
Vaccinated:2009-10-08
Onset:2009-10-14
Submitted:2009-10-16
Entered:2009-10-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U3203AA / 2 LA / IM
FLUN(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) (MEDIMMUNE)) / MEDIMMUNE VACCINES, INC. 500751P / 0 - / IN

Administered by: Private      Purchased by: Unknown
Symptoms: Apnoea, Blood albumin decreased, Blood alkaline phosphatase normal, Blood calcium decreased, Blood glucose normal, Bronchopneumonia, Cardiac arrest, Chills, Death, Electrocardiogram abnormal, Eosinophil count decreased, Full blood count abnormal, Haematocrit decreased, Haemoglobin decreased, Influenza, Leukopenia, Lividity, Lung consolidation, Monocyte count decreased, Neutrophil count decreased, Pallor, Pneumonia pneumococcal, Pulse absent, Pupil fixed, Red blood cell count decreased, Resuscitation, Trisomy 21, White blood cell count decreased, Drug screen positive, Red blood cell sedimentation rate increased, Red cell distribution width increased, Immunohistochemistry, Diffuse alveolar damage, Streptococcus identification test positive, Neisseria test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2009-10-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: Limping
Preexisting Conditions: H/O Leukemia 2002; Down''s Syndrome. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Down Syndrome. Cough, fever. Frequent colds. Discharge from eyes. Vomiting and diarrhea. Lymphadenopathy. Foot pain. CBC abnormal.
Allergies:
Diagnostic Lab Data: CBC: 2.5, 7.5, 21.3, 207; Sed rate 125. 10/20/09 ER records received service date 10/14/09. LABS and Diagnostics: EEG - Asystole. CHEM - Glucose 107 mg/dL (H) Calcium 3.5 mg/dL (L) Albumin 3.4 g/dL (L) Alk Phos 170 U/L (L). CBC - WBC 2.5 Thou/uL (L) RBC 2.57 Mill/uL (L) HGB 7.5 g/dL (L) HCT 27.3% (L) RDW 16.4% (H) Neut ABS 565 cells/uL (L) Mono ABS 33 cells/uL (L) Eosin 3 cells/uL (L)
CDC 'Split Type':

Write-up: None Stated. On 10/19/09, the PCP stated that coroner called him and told him that he found consolidation of the lungs on autopsy. Autopsy report is not complete yet. 10/20/09 ER records received service date 10/14/09. Assessment: Cardiac arrest. CPR initiated. Pupils fixed and dilated. Apnea, pale. Rigor, lividity. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Assessment: Death. Office staff unable to contact patient''s family, eventually visited patient''s home. learnd that patient was found dead at home and taken to ER. 11/3/09 Additional ER records received for service date 10/14/09. Found supine on floor at home apneic and pulseless. Cardiac arrest. CPR initiated. 12/8/09 Autopsy received. Pronounced dead on 10/13/2009 Final cause of death: Pneumococcal Pneumonia. Pandemic Influenza A. Additional Information Abstracted: Other contributing conditions - Leukopenia, history of leukemia, Down syndrome. Drug Screen Heart Blood: Dextromethorphan <0.10 ug/ml, Promethazine 0.11 ug/ml. /ksk 12/28/09 Pathology report received. Receipt date 10/23/2009. Sign out date 12/21/2009. Diagnosis: Lung - Diffuse alveolar damage and bronchopneumonia. Immunohistochemical and molecular evidence of novel influenza A H1N1. Immunohistochemical and molecular evidence of Streptococcus pneumoniae. Immunohistochemical evidence of Neisseria meningitidis without molecular confirmation. No immunohistochemical evidence of Group A Streptococcus or Haemophilus influenzae. All follow-up attempts have been completed per company SOPs. No further information available.


Changed on 5/13/2011

VAERS ID: 361353 Before After
VAERS Form:
Age:9.0
Gender:Female
Location:California
Vaccinated:2009-10-08
Onset:2009-10-14
Submitted:2009-10-16
Entered:2009-10-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U3203AA / 2 LA / IM
FLUN(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) (MEDIMMUNE)) / MEDIMMUNE VACCINES, INC. 500751P / 0 - / IN

Administered by: Private      Purchased by: Unknown
Symptoms: Apnoea, Blood albumin decreased, Blood alkaline phosphatase normal, Blood calcium decreased, Blood glucose normal, Bronchopneumonia, Cardiac arrest, Chills, Death, Electrocardiogram abnormal, Eosinophil count decreased, Full blood count abnormal, Haematocrit decreased, Haemoglobin decreased, Influenza, Leukopenia, Lividity, Lung consolidation, Monocyte count decreased, Neutrophil count decreased, Pallor, Pneumonia pneumococcal, Pulse absent, Pupil fixed, Red blood cell count decreased, Resuscitation, Trisomy 21, White blood cell count decreased, Drug screen positive, Red blood cell sedimentation rate increased, Red cell distribution width increased, Immunohistochemistry, Diffuse alveolar damage, Streptococcus identification test positive, Neisseria test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2009-10-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: Limping
Preexisting Conditions: H/O Leukemia 2002; Down''s Syndrome. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Down Syndrome. Cough, fever. Frequent colds. Discharge from eyes. Vomiting and diarrhea. Lymphadenopathy. Foot pain. CBC abnormal.
Allergies:
Diagnostic Lab Data: CBC: 2.5, 7.5, 21.3, 207; Sed rate 125. 10/20/09 ER records received service date 10/14/09. LABS and Diagnostics: EEG - Asystole. CHEM - Glucose 107 mg/dL (H) Calcium 3.5 mg/dL (L) Albumin 3.4 g/dL (L) Alk Phos 170 U/L (L). CBC - WBC 2.5 Thou/uL (L) RBC 2.57 Mill/uL (L) HGB 7.5 g/dL (L) HCT 27.3% (L) RDW 16.4% (H) Neut ABS 565 cells/uL (L) Mono ABS 33 cells/uL (L) Eosin 3 cells/uL (L)
CDC 'Split Type':

Write-up: None Stated. On 10/19/09, the PCP stated that coroner called him and told him that he found consolidation of the lungs on autopsy. Autopsy report is not complete yet. 10/20/09 ER records received service date 10/14/09. Assessment: Cardiac arrest. CPR initiated. Pupils fixed and dilated. Apnea, pale. Rigor, lividity. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Assessment: Death. Office staff unable to contact patient''s family, eventually visited patient''s home. learnd that patient was found dead at home and taken to ER. 11/3/09 Additional ER records received for service date 10/14/09. Found supine on floor at home apneic and pulseless. Cardiac arrest. CPR initiated. 12/8/09 Autopsy received. Pronounced dead on 10/13/2009 Final cause of death: Pneumococcal Pneumonia. Pandemic Influenza A. Additional Information Abstracted: Other contributing conditions - Leukopenia, history of leukemia, Down syndrome. Drug Screen Heart Blood: Dextromethorphan <0.10 ug/ml, Promethazine 0.11 ug/ml. /ksk 12/28/09 Pathology report received. Receipt date 10/23/2009. Sign out date 12/21/2009. Diagnosis: Lung - Diffuse alveolar damage and bronchopneumonia. Immunohistochemical and molecular evidence of novel influenza A H1N1. Immunohistochemical and molecular evidence of Streptococcus pneumoniae. Immunohistochemical evidence of Neisseria meningitidis without molecular confirmation. No immunohistochemical evidence of Group A Streptococcus or Haemophilus influenzae. All follow-up attempts have been completed per company SOPs. No further information available.


Changed on 6/11/2011

VAERS ID: 361353 Before After
VAERS Form:
Age:9.0
Gender:Female
Location:California
Vaccinated:2009-10-08
Onset:2009-10-14
Submitted:2009-10-16
Entered:2009-10-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U3203AA / 2 LA / IM
FLUN(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) (MEDIMMUNE)) / MEDIMMUNE VACCINES, INC. 500751P / 0 - / IN

Administered by: Private      Purchased by: Unknown
Symptoms: Apnoea, Blood albumin decreased, Blood alkaline phosphatase normal, Blood calcium decreased, Blood glucose normal, Bronchopneumonia, Cardiac arrest, Chills, Death, Electrocardiogram abnormal, Eosinophil count decreased, Full blood count abnormal, Haematocrit decreased, Haemoglobin decreased, Influenza, Leukopenia, Lividity, Lung consolidation, Monocyte count decreased, Neutrophil count decreased, Pallor, Pneumonia pneumococcal, Pulse absent, Pupil fixed, Red blood cell count decreased, Resuscitation, Trisomy 21, White blood cell count decreased, Drug screen positive, Red blood cell sedimentation rate increased, Red cell distribution width increased, Immunohistochemistry, Diffuse alveolar damage, Streptococcus identification test positive, Neisseria test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2009-10-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: Limping
Preexisting Conditions: H/O Leukemia 2002; Down''s Syndrome. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Down Syndrome. Cough, fever. Frequent colds. Discharge from eyes. Vomiting and diarrhea. Lymphadenopathy. Foot pain. CBC abnormal.
Allergies:
Diagnostic Lab Data: CBC: 2.5, 7.5, 21.3, 207; Sed rate 125. 10/20/09 ER records received service date 10/14/09. LABS and Diagnostics: EEG - Asystole. CHEM - Glucose 107 mg/dL (H) Calcium 3.5 mg/dL (L) Albumin 3.4 g/dL (L) Alk Phos 170 U/L (L). CBC - WBC 2.5 Thou/uL (L) RBC 2.57 Mill/uL (L) HGB 7.5 g/dL (L) HCT 27.3% (L) RDW 16.4% (H) Neut ABS 565 cells/uL (L) Mono ABS 33 cells/uL (L) Eosin 3 cells/uL (L)
CDC 'Split Type':

Write-up: None Stated. On 10/19/09, the PCP stated that coroner called him and told him that he found consolidation of the lungs on autopsy. Autopsy report is not complete yet. 10/20/09 ER records received service date 10/14/09. Assessment: Cardiac arrest. CPR initiated. Pupils fixed and dilated. Apnea, pale. Rigor, lividity. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Assessment: Death. Office staff unable to contact patient''s family, eventually visited patient''s home. learnd that patient was found dead at home and taken to ER. 11/3/09 Additional ER records received for service date 10/14/09. Found supine on floor at home apneic and pulseless. Cardiac arrest. CPR initiated. 12/8/09 Autopsy received. Pronounced dead on 10/13/2009 Final cause of death: Pneumococcal Pneumonia. Pandemic Influenza A. Additional Information Abstracted: Other contributing conditions - Leukopenia, history of leukemia, Down syndrome. Drug Screen Heart Blood: Dextromethorphan <0.10 ug/ml, Promethazine 0.11 ug/ml. /ksk 12/28/09 Pathology report received. Receipt date 10/23/2009. Sign out date 12/21/2009. Diagnosis: Lung - Diffuse alveolar damage and bronchopneumonia. Immunohistochemical and molecular evidence of novel influenza A H1N1. Immunohistochemical and molecular evidence of Streptococcus pneumoniae. Immunohistochemical evidence of Neisseria meningitidis without molecular confirmation. No immunohistochemical evidence of Group A Streptococcus or Haemophilus influenzae. All follow-up attempts have been completed per company SOPs. No further information available.


Changed on 7/12/2011

VAERS ID: 361353 Before After
VAERS Form:
Age:9.0
Gender:Female
Location:California
Vaccinated:2009-10-08
Onset:2009-10-14
Submitted:2009-10-16
Entered:2009-10-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U3203AA / 2 LA / IM
FLUN(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) (MEDIMMUNE)) INFLUENZA (H1N1) (H1N1 (MONOVALENT) (MEDIMMUNE) / MEDIMMUNE VACCINES, INC. 500751P / 0 - / IN

Administered by: Private      Purchased by: Unknown
Symptoms: Apnoea, Blood albumin decreased, Blood alkaline phosphatase normal, Blood calcium decreased, Blood glucose normal, Bronchopneumonia, Cardiac arrest, Chills, Death, Electrocardiogram abnormal, Eosinophil count decreased, Full blood count abnormal, Haematocrit decreased, Haemoglobin decreased, Influenza, Leukopenia, Lividity, Lung consolidation, Monocyte count decreased, Neutrophil count decreased, Pallor, Pneumonia pneumococcal, Pulse absent, Pupil fixed, Red blood cell count decreased, Resuscitation, Trisomy 21, White blood cell count decreased, Drug screen positive, Red blood cell sedimentation rate increased, Red cell distribution width increased, Immunohistochemistry, Diffuse alveolar damage, Streptococcus identification test positive, Neisseria test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2009-10-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: Limping
Preexisting Conditions: H/O Leukemia 2002; Down''s Syndrome. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Down Syndrome. Cough, fever. Frequent colds. Discharge from eyes. Vomiting and diarrhea. Lymphadenopathy. Foot pain. CBC abnormal.
Allergies:
Diagnostic Lab Data: CBC: 2.5, 7.5, 21.3, 207; Sed rate 125. 10/20/09 ER records received service date 10/14/09. LABS and Diagnostics: EEG - Asystole. CHEM - Glucose 107 mg/dL (H) Calcium 3.5 mg/dL (L) Albumin 3.4 g/dL (L) Alk Phos 170 U/L (L). CBC - WBC 2.5 Thou/uL (L) RBC 2.57 Mill/uL (L) HGB 7.5 g/dL (L) HCT 27.3% (L) RDW 16.4% (H) Neut ABS 565 cells/uL (L) Mono ABS 33 cells/uL (L) Eosin 3 cells/uL (L)
CDC 'Split Type':

Write-up: None Stated. On 10/19/09, the PCP stated that coroner called him and told him that he found consolidation of the lungs on autopsy. Autopsy report is not complete yet. 10/20/09 ER records received service date 10/14/09. Assessment: Cardiac arrest. CPR initiated. Pupils fixed and dilated. Apnea, pale. Rigor, lividity. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Assessment: Death. Office staff unable to contact patient''s family, eventually visited patient''s home. learnd that patient was found dead at home and taken to ER. 11/3/09 Additional ER records received for service date 10/14/09. Found supine on floor at home apneic and pulseless. Cardiac arrest. CPR initiated. 12/8/09 Autopsy received. Pronounced dead on 10/13/2009 Final cause of death: Pneumococcal Pneumonia. Pandemic Influenza A. Additional Information Abstracted: Other contributing conditions - Leukopenia, history of leukemia, Down syndrome. Drug Screen Heart Blood: Dextromethorphan <0.10 ug/ml, Promethazine 0.11 ug/ml. /ksk 12/28/09 Pathology report received. Receipt date 10/23/2009. Sign out date 12/21/2009. Diagnosis: Lung - Diffuse alveolar damage and bronchopneumonia. Immunohistochemical and molecular evidence of novel influenza A H1N1. Immunohistochemical and molecular evidence of Streptococcus pneumoniae. Immunohistochemical evidence of Neisseria meningitidis without molecular confirmation. No immunohistochemical evidence of Group A Streptococcus or Haemophilus influenzae. All follow-up attempts have been completed per company SOPs. No further information available.


Changed on 7/7/2013

VAERS ID: 361353 Before After
VAERS Form:
Age:9.0
Gender:Female
Location:California
Vaccinated:2009-10-08
Onset:2009-10-14
Submitted:2009-10-16
Entered:2009-10-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U3203AA / 2 LA / IM
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U3203AA / 2 LA / IM
FLUN(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) (MEDIMMUNE) / MEDIMMUNE VACCINES, INC. 500751P / 0 - / IN

Administered by: Private      Purchased by: Unknown
Symptoms: Apnoea, Blood albumin decreased, Blood alkaline phosphatase normal, Blood calcium decreased, Blood glucose normal, Bronchopneumonia, Cardiac arrest, Chills, Death, Electrocardiogram abnormal, Eosinophil count decreased, Full blood count abnormal, Haematocrit decreased, Haemoglobin decreased, Influenza, Leukopenia, Lividity, Lung consolidation, Monocyte count decreased, Neutrophil count decreased, Pallor, Pneumonia pneumococcal, Pulse absent, Pupil fixed, Red blood cell count decreased, Resuscitation, Trisomy 21, White blood cell count decreased, Drug screen positive, Red blood cell sedimentation rate increased, Red cell distribution width increased, Immunohistochemistry, Diffuse alveolar damage, Streptococcus identification test positive, Neisseria test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2009-10-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: Limping
Preexisting Conditions: H/O Leukemia 2002; Down''s Syndrome. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Down Syndrome. Cough, fever. Frequent colds. Discharge from eyes. Vomiting and diarrhea. Lymphadenopathy. Foot pain. CBC abnormal.
Allergies:
Diagnostic Lab Data: CBC: 2.5, 7.5, 21.3, 207; Sed rate 125. 10/20/09 ER records received service date 10/14/09. LABS and Diagnostics: EEG - Asystole. CHEM - Glucose 107 mg/dL (H) Calcium 3.5 mg/dL (L) Albumin 3.4 g/dL (L) Alk Phos 170 U/L (L). CBC - WBC 2.5 Thou/uL (L) RBC 2.57 Mill/uL (L) HGB 7.5 g/dL (L) HCT 27.3% (L) RDW 16.4% (H) Neut ABS 565 cells/uL (L) Mono ABS 33 cells/uL (L) Eosin 3 cells/uL (L)
CDC 'Split Type':

Write-up: None Stated. On 10/19/09, the PCP stated that coroner called him and told him that he found consolidation of the lungs on autopsy. Autopsy report is not complete yet. 10/20/09 ER records received service date 10/14/09. Assessment: Cardiac arrest. CPR initiated. Pupils fixed and dilated. Apnea, pale. Rigor, lividity. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Assessment: Death. Office staff unable to contact patient''s family, eventually visited patient''s home. learnd that patient was found dead at home and taken to ER. 11/3/09 Additional ER records received for service date 10/14/09. Found supine on floor at home apneic and pulseless. Cardiac arrest. CPR initiated. 12/8/09 Autopsy received. Pronounced dead on 10/13/2009 Final cause of death: Pneumococcal Pneumonia. Pandemic Influenza A. Additional Information Abstracted: Other contributing conditions - Leukopenia, history of leukemia, Down syndrome. Drug Screen Heart Blood: Dextromethorphan <0.10 ug/ml, Promethazine 0.11 ug/ml. /ksk 12/28/09 Pathology report received. Receipt date 10/23/2009. Sign out date 12/21/2009. Diagnosis: Lung - Diffuse alveolar damage and bronchopneumonia. Immunohistochemical and molecular evidence of novel influenza A H1N1. Immunohistochemical and molecular evidence of Streptococcus pneumoniae. Immunohistochemical evidence of Neisseria meningitidis without molecular confirmation. No immunohistochemical evidence of Group A Streptococcus or Haemophilus influenzae. All follow-up attempts have been completed per company SOPs. No further information available.


Changed on 6/14/2014

VAERS ID: 361353 Before After
VAERS Form:
Age:9.0
Gender:Female
Location:California
Vaccinated:2009-10-08
Onset:2009-10-14
Submitted:2009-10-16
Entered:2009-10-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U3203AA / 2 LA / IM
FLUN(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) (MEDIMMUNE) / MEDIMMUNE VACCINES, INC. 500751P / 0 - / IN

Administered by: Private      Purchased by: Unknown
Symptoms: Apnoea, Blood albumin decreased, Blood alkaline phosphatase normal, Blood calcium decreased, Blood glucose normal, Bronchopneumonia, Cardiac arrest, Chills, Death, Electrocardiogram abnormal, Eosinophil count decreased, Full blood count abnormal, Haematocrit decreased, Haemoglobin decreased, Influenza, Leukopenia, Lividity, Lung consolidation, Monocyte count decreased, Neutrophil count decreased, Pallor, Pneumonia pneumococcal, Pulse absent, Pupil fixed, Red blood cell count decreased, Resuscitation, Trisomy 21, White blood cell count decreased, Drug screen positive, Red blood cell sedimentation rate increased, Red cell distribution width increased, Immunohistochemistry, Diffuse alveolar damage, Streptococcus identification test positive, Neisseria test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2009-10-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: Limping
Preexisting Conditions: H/O Leukemia 2002; Down''s Syndrome. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Down Syndrome. Cough, fever. Frequent colds. Discharge from eyes. Vomiting and diarrhea. Lymphadenopathy. Foot pain. CBC abnormal.
Allergies:
Diagnostic Lab Data: CBC: 2.5, 7.5, 21.3, 207; Sed rate 125. 10/20/09 ER records received service date 10/14/09. LABS and Diagnostics: EEG - Asystole. CHEM - Glucose 107 mg/dL (H) Calcium 3.5 mg/dL (L) Albumin 3.4 g/dL (L) Alk Phos 170 U/L (L). CBC - WBC 2.5 Thou/uL (L) RBC 2.57 Mill/uL (L) HGB 7.5 g/dL (L) HCT 27.3% (L) RDW 16.4% (H) Neut ABS 565 cells/uL (L) Mono ABS 33 cells/uL (L) Eosin 3 cells/uL (L)
CDC 'Split Type':

Write-up: None Stated. On 10/19/09, the PCP stated that coroner called him and told him that he found consolidation of the lungs on autopsy. Autopsy report is not complete yet. 10/20/09 ER records received service date 10/14/09. Assessment: Cardiac arrest. CPR initiated. Pupils fixed and dilated. Apnea, pale. Rigor, lividity. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Assessment: Death. Office staff unable to contact patient''s family, eventually visited patient''s home. learnd that patient was found dead at home and taken to ER. 11/3/09 Additional ER records received for service date 10/14/09. Found supine on floor at home apneic and pulseless. Cardiac arrest. CPR initiated. 12/8/09 Autopsy received. Pronounced dead on 10/13/2009 Final cause of death: Pneumococcal Pneumonia. Pandemic Influenza A. Additional Information Abstracted: Other contributing conditions - Leukopenia, history of leukemia, Down syndrome. Drug Screen Heart Blood: Dextromethorphan <0.10 ug/ml, Promethazine 0.11 ug/ml. /ksk 12/28/09 Pathology report received. Receipt date 10/23/2009. Sign out date 12/21/2009. Diagnosis: Lung - Diffuse alveolar damage and bronchopneumonia. Immunohistochemical and molecular evidence of novel influenza A H1N1. Immunohistochemical and molecular evidence of Streptococcus pneumoniae. Immunohistochemical evidence of Neisseria meningitidis without molecular confirmation. No immunohistochemical evidence of Group A Streptococcus or Haemophilus influenzae. All follow-up attempts have been completed per company SOPs. No further information available.


Changed on 2/14/2017

VAERS ID: 361353 Before After
VAERS Form:
Age:9.0
Gender:Female
Location:California
Vaccinated:2009-10-08
Onset:2009-10-14
Submitted:2009-10-16
Entered:2009-10-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U3203AA / 2 LA / IM
FLUN(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) (MEDIMMUNE) INFLUENZA (H1N1) (H1N1 (MONOVALENT) (MEDIMMUNE)) / MEDIMMUNE VACCINES, INC. 500751P / 0 - / IN

Administered by: Private      Purchased by: Unknown
Symptoms: Apnoea, Blood albumin decreased, Blood alkaline phosphatase normal, Blood calcium decreased, Blood glucose normal, Bronchopneumonia, Cardiac arrest, Chills, Death, Electrocardiogram abnormal, Eosinophil count decreased, Full blood count abnormal, Haematocrit decreased, Haemoglobin decreased, Influenza, Leukopenia, Lividity, Lung consolidation, Monocyte count decreased, Neutrophil count decreased, Pallor, Pneumonia pneumococcal, Pulse absent, Pupil fixed, Red blood cell count decreased, Resuscitation, Trisomy 21, White blood cell count decreased, Drug screen positive, Red blood cell sedimentation rate increased, Red cell distribution width increased, Immunohistochemistry, Diffuse alveolar damage, Streptococcus identification test positive, Neisseria test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2009-10-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: Limping
Preexisting Conditions: H/O Leukemia 2002; Down''s Syndrome. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Down Syndrome. Cough, fever. Frequent colds. Discharge from eyes. Vomiting and diarrhea. Lymphadenopathy. Foot pain. CBC abnormal.
Allergies:
Diagnostic Lab Data: CBC: 2.5, 7.5, 21.3, 207; Sed rate 125. 10/20/09 ER records received service date 10/14/09. LABS and Diagnostics: EEG - Asystole. CHEM - Glucose 107 mg/dL (H) Calcium 3.5 mg/dL (L) Albumin 3.4 g/dL (L) Alk Phos 170 U/L (L). CBC - WBC 2.5 Thou/uL (L) RBC 2.57 Mill/uL (L) HGB 7.5 g/dL (L) HCT 27.3% (L) RDW 16.4% (H) Neut ABS 565 cells/uL (L) Mono ABS 33 cells/uL (L) Eosin 3 cells/uL (L)
CDC 'Split Type':

Write-up: None Stated. On 10/19/09, the PCP stated that coroner called him and told him that he found consolidation of the lungs on autopsy. Autopsy report is not complete yet. 10/20/09 ER records received service date 10/14/09. Assessment: Cardiac arrest. CPR initiated. Pupils fixed and dilated. Apnea, pale. Rigor, lividity. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Assessment: Death. Office staff unable to contact patient''s family, eventually visited patient''s home. learnd that patient was found dead at home and taken to ER. 11/3/09 Additional ER records received for service date 10/14/09. Found supine on floor at home apneic and pulseless. Cardiac arrest. CPR initiated. 12/8/09 Autopsy received. Pronounced dead on 10/13/2009 Final cause of death: Pneumococcal Pneumonia. Pandemic Influenza A. Additional Information Abstracted: Other contributing conditions - Leukopenia, history of leukemia, Down syndrome. Drug Screen Heart Blood: Dextromethorphan <0.10 ug/ml, Promethazine 0.11 ug/ml. /ksk 12/28/09 Pathology report received. Receipt date 10/23/2009. Sign out date 12/21/2009. Diagnosis: Lung - Diffuse alveolar damage and bronchopneumonia. Immunohistochemical and molecular evidence of novel influenza A H1N1. Immunohistochemical and molecular evidence of Streptococcus pneumoniae. Immunohistochemical evidence of Neisseria meningitidis without molecular confirmation. No immunohistochemical evidence of Group A Streptococcus or Haemophilus influenzae. All follow-up attempts have been completed per company SOPs. No further information available.


Changed on 9/14/2017

VAERS ID: 361353 Before After
VAERS Form:(blank) 1
Age:9.0
Gender:Female
Location:California
Vaccinated:2009-10-08
Onset:2009-10-14
Submitted:2009-10-16
Entered:2009-10-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U3203AA / 2 3 LA / IM
FLUN(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) (MEDIMMUNE)) / MEDIMMUNE VACCINES, INC. 500751P / 0 1 - NS / IN

Administered by: Private      Purchased by: Unknown
Symptoms: Blood alkaline phosphatase normal, Blood glucose normal, Death, Full blood count abnormal, Haematocrit decreased, Haemoglobin decreased, Pupil fixed, Red blood cell sedimentation rate increased, Immunohistochemistry, Neisseria test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2009-10-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: Limping
Preexisting Conditions: H/O Leukemia 2002; Down''s Syndrome. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Down Syndrome. Cough, fever. Frequent colds. Discharge from eyes. Vomiting and diarrhea. Lymphadenopathy. Foot pain. CBC abnormal.
Allergies:
Diagnostic Lab Data: CBC: 2.5, 7.5, 21.3, 207; Sed rate 125. 10/20/09 ER records received service date 10/14/09. LABS and Diagnostics: EEG - Asystole. CHEM - Glucose 107 mg/dL (H) Calcium 3.5 mg/dL (L) Albumin 3.4 g/dL (L) Alk Phos 170 U/L (L). CBC - WBC 2.5 Thou/uL (L) RBC 2.57 Mill/uL (L) HGB 7.5 g/dL (L) HCT 27.3% (L) RDW 16.4% (H) Neut ABS 565 cells/uL (L) Mono ABS 33 cells/uL (L) Eosin 3 cells/uL (L)
CDC 'Split Type':

Write-up: None Stated. On 10/19/09, the PCP stated that coroner called him and told him that he found consolidation of the lungs on autopsy. Autopsy report is not complete yet. 10/20/09 ER records received service date 10/14/09. Assessment: Cardiac arrest. CPR initiated. Pupils fixed and dilated. Apnea, pale. Rigor, lividity. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Assessment: Death. Office staff unable to contact patient''s family, eventually visited patient''s home. learnd that patient was found dead at home and taken to ER. 11/3/09 Additional ER records received for service date 10/14/09. Found supine on floor at home apneic and pulseless. Cardiac arrest. CPR initiated. 12/8/09 Autopsy received. Pronounced dead on 10/13/2009 Final cause of death: Pneumococcal Pneumonia. Pandemic Influenza A. Additional Information Abstracted: Other contributing conditions - Leukopenia, history of leukemia, Down syndrome. Drug Screen Heart Blood: Dextromethorphan <0.10 ug/ml, Promethazine 0.11 ug/ml. /ksk 12/28/09 Pathology report received. Receipt date 10/23/2009. Sign out date 12/21/2009. Diagnosis: Lung - Diffuse alveolar damage and bronchopneumonia. Immunohistochemical and molecular evidence of novel influenza A H1N1. Immunohistochemical and molecular evidence of Streptococcus pneumoniae. Immunohistochemical evidence of Neisseria meningitidis without molecular confirmation. No immunohistochemical evidence of Group A Streptococcus or Haemophilus influenzae. All follow-up attempts have been completed per company SOPs. No further information available.


Changed on 2/14/2018

VAERS ID: 361353 Before After
VAERS Form:1
Age:9.0
Gender:Female
Location:California
Vaccinated:2009-10-08
Onset:2009-10-14
Submitted:2009-10-16
Entered:2009-10-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U3203AA / 3 LA / IM
FLUN(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) (MEDIMMUNE)) / MEDIMMUNE VACCINES, INC. 500751P / 1 NS / IN

Administered by: Private      Purchased by: Unknown
Symptoms: Blood alkaline phosphatase normal, Blood glucose normal, Death, Full blood count abnormal, Haematocrit decreased, Haemoglobin decreased, Pupil fixed, Red blood cell sedimentation rate increased, Immunohistochemistry, Neisseria test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2009-10-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: Limping
Preexisting Conditions: H/O Leukemia 2002; Down''s Syndrome. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Down Syndrome. Cough, fever. Frequent colds. Discharge from eyes. Vomiting and diarrhea. Lymphadenopathy. Foot pain. CBC abnormal.
Allergies:
Diagnostic Lab Data: CBC: 2.5, 7.5, 21.3, 207; Sed rate 125. 10/20/09 ER records received service date 10/14/09. LABS and Diagnostics: EEG - Asystole. CHEM - Glucose 107 mg/dL (H) Calcium 3.5 mg/dL (L) Albumin 3.4 g/dL (L) Alk Phos 170 U/L (L). CBC - WBC 2.5 Thou/uL (L) RBC 2.57 Mill/uL (L) HGB 7.5 g/dL (L) HCT 27.3% (L) RDW 16.4% (H) Neut ABS 565 cells/uL (L) Mono ABS 33 cells/uL (L) Eosin 3 cells/uL (L)
CDC 'Split Type':

Write-up: None Stated. On 10/19/09, the PCP stated that coroner called him and told him that he found consolidation of the lungs on autopsy. Autopsy report is not complete yet. 10/20/09 ER records received service date 10/14/09. Assessment: Cardiac arrest. CPR initiated. Pupils fixed and dilated. Apnea, pale. Rigor, lividity. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Assessment: Death. Office staff unable to contact patient''s family, eventually visited patient''s home. learnd that patient was found dead at home and taken to ER. 11/3/09 Additional ER records received for service date 10/14/09. Found supine on floor at home apneic and pulseless. Cardiac arrest. CPR initiated. 12/8/09 Autopsy received. Pronounced dead on 10/13/2009 Final cause of death: Pneumococcal Pneumonia. Pandemic Influenza A. Additional Information Abstracted: Other contributing conditions - Leukopenia, history of leukemia, Down syndrome. Drug Screen Heart Blood: Dextromethorphan <0.10 ug/ml, Promethazine 0.11 ug/ml. /ksk 12/28/09 Pathology report received. Receipt date 10/23/2009. Sign out date 12/21/2009. Diagnosis: Lung - Diffuse alveolar damage and bronchopneumonia. Immunohistochemical and molecular evidence of novel influenza A H1N1. Immunohistochemical and molecular evidence of Streptococcus pneumoniae. Immunohistochemical evidence of Neisseria meningitidis without molecular confirmation. No immunohistochemical evidence of Group A Streptococcus or Haemophilus influenzae. All follow-up attempts have been completed per company SOPs. No further information available.


Changed on 6/14/2018

VAERS ID: 361353 Before After
VAERS Form:1
Age:9.0
Gender:Female
Location:California
Vaccinated:2009-10-08
Onset:2009-10-14
Submitted:2009-10-16
Entered:2009-10-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U3203AA / 3 LA / IM
FLUN(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) (MEDIMMUNE)) / MEDIMMUNE VACCINES, INC. 500751P / 1 NS / IN

Administered by: Private      Purchased by: Unknown
Symptoms: Blood alkaline phosphatase normal, Blood glucose normal, Death, Full blood count abnormal, Haematocrit decreased, Haemoglobin decreased, Pupil fixed, Red blood cell sedimentation rate increased, Immunohistochemistry, Neisseria test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2009-10-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: Limping
Preexisting Conditions: H/O Leukemia 2002; Down''s Syndrome. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Down Syndrome. Cough, fever. Frequent colds. Discharge from eyes. Vomiting and diarrhea. Lymphadenopathy. Foot pain. CBC abnormal.
Allergies:
Diagnostic Lab Data: CBC: 2.5, 7.5, 21.3, 207; Sed rate 125. 10/20/09 ER records received service date 10/14/09. LABS and Diagnostics: EEG - Asystole. CHEM - Glucose 107 mg/dL (H) Calcium 3.5 mg/dL (L) Albumin 3.4 g/dL (L) Alk Phos 170 U/L (L). CBC - WBC 2.5 Thou/uL (L) RBC 2.57 Mill/uL (L) HGB 7.5 g/dL (L) HCT 27.3% (L) RDW 16.4% (H) Neut ABS 565 cells/uL (L) Mono ABS 33 cells/uL (L) Eosin 3 cells/uL (L)
CDC 'Split Type':

Write-up: None Stated. On 10/19/09, the PCP stated that coroner called him and told him that he found consolidation of the lungs on autopsy. Autopsy report is not complete yet. 10/20/09 ER records received service date 10/14/09. Assessment: Cardiac arrest. CPR initiated. Pupils fixed and dilated. Apnea, pale. Rigor, lividity. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Assessment: Death. Office staff unable to contact patient''s family, eventually visited patient''s home. learnd that patient was found dead at home and taken to ER. 11/3/09 Additional ER records received for service date 10/14/09. Found supine on floor at home apneic and pulseless. Cardiac arrest. CPR initiated. 12/8/09 Autopsy received. Pronounced dead on 10/13/2009 Final cause of death: Pneumococcal Pneumonia. Pandemic Influenza A. Additional Information Abstracted: Other contributing conditions - Leukopenia, history of leukemia, Down syndrome. Drug Screen Heart Blood: Dextromethorphan <0.10 ug/ml, Promethazine 0.11 ug/ml. /ksk 12/28/09 Pathology report received. Receipt date 10/23/2009. Sign out date 12/21/2009. Diagnosis: Lung - Diffuse alveolar damage and bronchopneumonia. Immunohistochemical and molecular evidence of novel influenza A H1N1. Immunohistochemical and molecular evidence of Streptococcus pneumoniae. Immunohistochemical evidence of Neisseria meningitidis without molecular confirmation. No immunohistochemical evidence of Group A Streptococcus or Haemophilus influenzae. All follow-up attempts have been completed per company SOPs. No further information available.


Changed on 8/14/2018

VAERS ID: 361353 Before After
VAERS Form:1
Age:9.0
Gender:Female
Location:California
Vaccinated:2009-10-08
Onset:2009-10-14
Submitted:2009-10-16
Entered:2009-10-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U3203AA / 3 LA / IM
FLUN(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) (MEDIMMUNE)) / MEDIMMUNE VACCINES, INC. 500751P / 1 NS / IN

Administered by: Private      Purchased by: Unknown
Symptoms: Blood alkaline phosphatase normal, Blood glucose normal, Death, Full blood count abnormal, Haematocrit decreased, Haemoglobin decreased, Pupil fixed, Red blood cell sedimentation rate increased, Immunohistochemistry, Neisseria test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2009-10-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: Limping
Preexisting Conditions: H/O Leukemia 2002; Down''s Syndrome. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Down Syndrome. Cough, fever. Frequent colds. Discharge from eyes. Vomiting and diarrhea. Lymphadenopathy. Foot pain. CBC abnormal.
Allergies:
Diagnostic Lab Data: CBC: 2.5, 7.5, 21.3, 207; Sed rate 125. 10/20/09 ER records received service date 10/14/09. LABS and Diagnostics: EEG - Asystole. CHEM - Glucose 107 mg/dL (H) Calcium 3.5 mg/dL (L) Albumin 3.4 g/dL (L) Alk Phos 170 U/L (L). CBC - WBC 2.5 Thou/uL (L) RBC 2.57 Mill/uL (L) HGB 7.5 g/dL (L) HCT 27.3% (L) RDW 16.4% (H) Neut ABS 565 cells/uL (L) Mono ABS 33 cells/uL (L) Eosin 3 cells/uL (L)
CDC 'Split Type':

Write-up: None Stated. On 10/19/09, the PCP stated that coroner called him and told him that he found consolidation of the lungs on autopsy. Autopsy report is not complete yet. 10/20/09 ER records received service date 10/14/09. Assessment: Cardiac arrest. CPR initiated. Pupils fixed and dilated. Apnea, pale. Rigor, lividity. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Assessment: Death. Office staff unable to contact patient''s family, eventually visited patient''s home. learnd that patient was found dead at home and taken to ER. 11/3/09 Additional ER records received for service date 10/14/09. Found supine on floor at home apneic and pulseless. Cardiac arrest. CPR initiated. 12/8/09 Autopsy received. Pronounced dead on 10/13/2009 Final cause of death: Pneumococcal Pneumonia. Pandemic Influenza A. Additional Information Abstracted: Other contributing conditions - Leukopenia, history of leukemia, Down syndrome. Drug Screen Heart Blood: Dextromethorphan <0.10 ug/ml, Promethazine 0.11 ug/ml. /ksk 12/28/09 Pathology report received. Receipt date 10/23/2009. Sign out date 12/21/2009. Diagnosis: Lung - Diffuse alveolar damage and bronchopneumonia. Immunohistochemical and molecular evidence of novel influenza A H1N1. Immunohistochemical and molecular evidence of Streptococcus pneumoniae. Immunohistochemical evidence of Neisseria meningitidis without molecular confirmation. No immunohistochemical evidence of Group A Streptococcus or Haemophilus influenzae. All follow-up attempts have been completed per company SOPs. No further information available.


Changed on 9/14/2018

VAERS ID: 361353 Before After
VAERS Form:1
Age:9.0
Gender:Female
Location:California
Vaccinated:2009-10-08
Onset:2009-10-14
Submitted:2009-10-16
Entered:2009-10-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U3203AA / 3 LA / IM
FLUN(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) (MEDIMMUNE)) / MEDIMMUNE VACCINES, INC. 500751P / 1 NS / IN

Administered by: Private      Purchased by: Unknown
Symptoms: Blood alkaline phosphatase normal, Blood glucose normal, Death, Full blood count abnormal, Haematocrit decreased, Haemoglobin decreased, Pupil fixed, Red blood cell sedimentation rate increased, Immunohistochemistry, Neisseria test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2009-10-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: Limping
Preexisting Conditions: H/O Leukemia 2002; Down''s Syndrome. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Down Syndrome. Cough, fever. Frequent colds. Discharge from eyes. Vomiting and diarrhea. Lymphadenopathy. Foot pain. CBC abnormal.
Allergies:
Diagnostic Lab Data: CBC: 2.5, 7.5, 21.3, 207; Sed rate 125. 10/20/09 ER records received service date 10/14/09. LABS and Diagnostics: EEG - Asystole. CHEM - Glucose 107 mg/dL (H) Calcium 3.5 mg/dL (L) Albumin 3.4 g/dL (L) Alk Phos 170 U/L (L). CBC - WBC 2.5 Thou/uL (L) RBC 2.57 Mill/uL (L) HGB 7.5 g/dL (L) HCT 27.3% (L) RDW 16.4% (H) Neut ABS 565 cells/uL (L) Mono ABS 33 cells/uL (L) Eosin 3 cells/uL (L)
CDC 'Split Type':

Write-up: None Stated. On 10/19/09, the PCP stated that coroner called him and told him that he found consolidation of the lungs on autopsy. Autopsy report is not complete yet. 10/20/09 ER records received service date 10/14/09. Assessment: Cardiac arrest. CPR initiated. Pupils fixed and dilated. Apnea, pale. Rigor, lividity. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Assessment: Death. Office staff unable to contact patient''s family, eventually visited patient''s home. learnd that patient was found dead at home and taken to ER. 11/3/09 Additional ER records received for service date 10/14/09. Found supine on floor at home apneic and pulseless. Cardiac arrest. CPR initiated. 12/8/09 Autopsy received. Pronounced dead on 10/13/2009 Final cause of death: Pneumococcal Pneumonia. Pandemic Influenza A. Additional Information Abstracted: Other contributing conditions - Leukopenia, history of leukemia, Down syndrome. Drug Screen Heart Blood: Dextromethorphan <0.10 ug/ml, Promethazine 0.11 ug/ml. /ksk 12/28/09 Pathology report received. Receipt date 10/23/2009. Sign out date 12/21/2009. Diagnosis: Lung - Diffuse alveolar damage and bronchopneumonia. Immunohistochemical and molecular evidence of novel influenza A H1N1. Immunohistochemical and molecular evidence of Streptococcus pneumoniae. Immunohistochemical evidence of Neisseria meningitidis without molecular confirmation. No immunohistochemical evidence of Group A Streptococcus or Haemophilus influenzae. All follow-up attempts have been completed per company SOPs. No further information available.


Changed on 10/14/2018

VAERS ID: 361353 Before After
VAERS Form:1
Age:9.0
Gender:Female
Location:California
Vaccinated:2009-10-08
Onset:2009-10-14
Submitted:2009-10-16
Entered:2009-10-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U3203AA / 3 LA / IM
FLUN(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) (MEDIMMUNE)) / MEDIMMUNE VACCINES, INC. 500751P / 1 NS / IN

Administered by: Private      Purchased by: Unknown
Symptoms: Blood alkaline phosphatase normal, Blood glucose normal, Death, Full blood count abnormal, Haematocrit decreased, Haemoglobin decreased, Pupil fixed, Red blood cell sedimentation rate increased, Immunohistochemistry, Neisseria test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2009-10-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: Limping
Preexisting Conditions: H/O Leukemia 2002; Down''s Syndrome. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Down Syndrome. Cough, fever. Frequent colds. Discharge from eyes. Vomiting and diarrhea. Lymphadenopathy. Foot pain. CBC abnormal.
Allergies:
Diagnostic Lab Data: CBC: 2.5, 7.5, 21.3, 207; Sed rate 125. 10/20/09 ER records received service date 10/14/09. LABS and Diagnostics: EEG - Asystole. CHEM - Glucose 107 mg/dL (H) Calcium 3.5 mg/dL (L) Albumin 3.4 g/dL (L) Alk Phos 170 U/L (L). CBC - WBC 2.5 Thou/uL (L) RBC 2.57 Mill/uL (L) HGB 7.5 g/dL (L) HCT 27.3% (L) RDW 16.4% (H) Neut ABS 565 cells/uL (L) Mono ABS 33 cells/uL (L) Eosin 3 cells/uL (L)
CDC 'Split Type':

Write-up: None Stated. On 10/19/09, the PCP stated that coroner called him and told him that he found consolidation of the lungs on autopsy. Autopsy report is not complete yet. 10/20/09 ER records received service date 10/14/09. Assessment: Cardiac arrest. CPR initiated. Pupils fixed and dilated. Apnea, pale. Rigor, lividity. 1022/09 PCP /Nursing medical records received, service dates 11/11/03 to 10/14/09. Assessment: Death. Office staff unable to contact patient''s family, eventually visited patient''s home. learnd that patient was found dead at home and taken to ER. 11/3/09 Additional ER records received for service date 10/14/09. Found supine on floor at home apneic and pulseless. Cardiac arrest. CPR initiated. 12/8/09 Autopsy received. Pronounced dead on 10/13/2009 Final cause of death: Pneumococcal Pneumonia. Pandemic Influenza A. Additional Information Abstracted: Other contributing conditions - Leukopenia, history of leukemia, Down syndrome. Drug Screen Heart Blood: Dextromethorphan <0.10 ug/ml, Promethazine 0.11 ug/ml. /ksk 12/28/09 Pathology report received. Receipt date 10/23/2009. Sign out date 12/21/2009. Diagnosis: Lung - Diffuse alveolar damage and bronchopneumonia. Immunohistochemical and molecular evidence of novel influenza A H1N1. Immunohistochemical and molecular evidence of Streptococcus pneumoniae. Immunohistochemical evidence of Neisseria meningitidis without molecular confirmation. No immunohistochemical evidence of Group A Streptococcus or Haemophilus influenzae. All follow-up attempts have been completed per company SOPs. No further information available.

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