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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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http://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20110513&IDNUMBER=413829


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