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This is VAERS ID 372910

Case Details

VAERS ID: 372910 (history)  
Form: Version 1.0  
Age: 18.0  
Sex: Female  
Location: Foreign  
   Days after vaccination:369
Submitted: 2009-12-10
   Days after onset:79
Entered: 2009-12-11
   Days after submission:1
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Unknown       Purchased by: Unknown
Symptoms: Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2009-09-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Herpes virus infection
Preexisting Conditions:
Diagnostic Lab Data: Unknown
CDC Split Type: WAES0912USA00953

Write-up: Information has been received from the agency via Case Line listing via CSL, as part of a business agreement, concerning an 18 year old female patient with disseminated herpes viral disease who on 17-MAR-2009 was vaccinated with the third dose of GARDASIL (batch #NJ11440, lot# 1283U). The second suspect therapy included DEPO-PROVERA which was administered IM, 600 mg yearly, from 2007 October to 2009 January. On 22-SEP-2009 the patient developed sudden death (severe). It was unknown if the patient sought medical attention. A lot check has been initiated. No further information is available.

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