This is VAERS ID 413829

(NOTE: This result is from the 5/13/2011 version of the VAERS database)

Case Details

VAERS ID:	413829 (history)
Form:	Version .0
Age:	0.4
Gender:	Male
Location:	New York

Vaccinated:	2010-12-17
Onset:	2010-12-21
Days after vaccination:	4
Submitted:	2010-12-30
Days after onset:	9
Entered:	2010-12-31
Days after submission:	1

Vaccination / Manufacturer	Lot / Dose	Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS	AC21B256BA / 1	RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS	A41FB109A / 1	- / PO

Administered by: Private Purchased by: Private
Symptoms: Abdominal X-ray, Enema administration, Intussusception, Vomiting projectile, X-ray abnormal
SMQs:, Acute pancreatitis (broad), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Denies
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Abdominal Xray revealed intussusception 4 days post ROTARIX vaccine, enema given to dx intussusception & treat.
CDC Split Type:

Write-up: On 12/17/10 pt received ROTARIX vaccine. On 12/21/10 pt''s mother reported projectile vomiting. Pt''s mother monitored pt and called back due to continued vomiting. Pt sent to ER for evaluation. Abdominal xray at Hospital revealed intussusception. Pt admitted and dc''d on 12/24/10. (3 days in pt.).

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