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This is VAERS ID 393611

(NOTE: This result is from the 8/31/2010 version of the VAERS database)

Case Details

VAERS ID: 393611 (history)  
Form: Version .0  
Age: 0.2  
Gender: Male  
Location: Colorado  
Vaccinated:2010-07-14
Onset:2010-07-20
   Days after vaccination:6
Submitted: 2010-07-26
   Days after onset:6
Entered: 2010-07-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B249BA / 0 UN / SC
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1421Y / 0 UN / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH E60221 / 0 UN / UN
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41BB088A/A41FB / 0 - / PO

Administered by: Private       Purchased by: Private
Symptoms: Abdominal pain, Barium enema, Computerised tomogram abnormal, Haematochezia, Intussusception, Small intestinal intussusception reduction
SMQs:, Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Retroperitoneal fibrosis (broad), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Gastrointestinal haemorrhage (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Ischaemic colitis (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: 6 days after vaccines developed crampy abdominal pain and bloody stools. CT showed ileocecal intussusception. Surgical reduction was performed after barium enema failed.


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