| VAERS ID: |
37837 (history) |
| Form: |
Version 1.0 |
| Age: |
1.3 |
| Sex: |
Male |
| Location: |
California |
| Vaccinated: | 1991-07-12 |
| Onset: | 1991-07-30 |
| Days after vaccination: | 18 |
| Submitted: |
1991-12-05 |
| Days after onset: | 128 |
| Entered: |
1991-12-09 |
| Days after submission: | 4 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. |
0862T / 1 |
LL / SC |
Administered by: Private Purchased by: Private
Symptoms: Apnoea,
Cardiac arrest,
Sudden infant death syndrome
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Cardiomyopathy (broad), Neonatal disorders (narrow), Respiratory failure (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 1991-07-30
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, ? days
Extended hospital stay? No
Previous Vaccinations: AUG90 @ 6mos w/DTP #3 pt exp rxn;~ ()~~~In patient
Other Medications: APAP, Phenobarb
Current Illness: NONE
Preexisting Conditions: seizure disorder
Allergies:
Diagnostic Lab Data: Autospy signed out as SIDS;
CDC Split Type:
Write-up: Pt has onset of sz disorder w/fever AUG90 p/3rd DTP/OPV/HBOC; recurrent afebrile sz; on 12JUL91 had MMR died of respiratory/cardiac arrest 30JUL cause undetermined; |
