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Administered by: Unknown      Purchased by: Unknown
Symptoms: Injection site mass, Similar reaction on previous exposure to drug

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type': 201007119

Write-up: Initial report received from a health care professional on 22 December 2010. A 15 year-old female patient had received on an unknown day in 2006 a right deltoid dose of ADACEL (lot number C2384AA, expiration date 04 May 2008, route not reported), and subsequently received a first intramuscular right deltoid injection of MENACTRA (lot number U2230AA) on 04 May 2007; and on 02 November 2007 she received an intramuscular right deltoid injection of FLUZONE (lot number U2436AA), and an intramuscular left arm (also documented as right arm in patient''s chart) injection of GARDASIL (manufacturer Merck, lot number unknown). The patient was in the physician''s office around 22 December 2010 and during her physical examination it was noted she had a 6 x 6.5 cm lump under the skin at the right deltoid. It was reported by the patient''s mother that the lump had been there since the patient''s last vaccinations 3-4 years ago. The event had not been reported to the physician prior to that time. Relevant medical history was unknown. Per the reporter, no relevant diagnostic tests/laboratory data were performed. Documents held by sender: None.

Changed on 9/14/2017

Administered by: Unknown      Purchased by: Unknown
Symptoms: Injection site mass, Similar reaction on previous exposure to drug

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type': 201007119

Write-up: Initial report received from a health care professional on 22 December 2010. A 15 year-old female patient had received on an unknown day in 2006 a right deltoid dose of ADACEL (lot number C2384AA, expiration date 04 May 2008, route not reported), and subsequently received a first intramuscular right deltoid injection of MENACTRA (lot number U2230AA) on 04 May 2007; and on 02 November 2007 she received an intramuscular right deltoid injection of FLUZONE (lot number U2436AA), and an intramuscular left arm (also documented as right arm in patient''s chart) injection of GARDASIL (manufacturer Merck, lot number unknown). The patient was in the physician''s office around 22 December 2010 and during her physical examination it was noted she had a 6 x 6.5 cm lump under the skin at the right deltoid. It was reported by the patient''s mother that the lump had been there since the patient''s last vaccinations 3-4 years ago. The event had not been reported to the physician prior to that time. Relevant medical history was unknown. Per the reporter, no relevant diagnostic tests/laboratory data were performed. Documents held by sender: None.

Changed on 2/14/2018

Administered by: Unknown      Purchased by: Unknown
Symptoms: Injection site mass, Similar reaction on previous exposure to drug

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type': 201007119

Write-up: Initial report received from a health care professional on 22 December 2010. A 15 year-old female patient had received on an unknown day in 2006 a right deltoid dose of ADACEL (lot number C2384AA, expiration date 04 May 2008, route not reported), and subsequently received a first intramuscular right deltoid injection of MENACTRA (lot number U2230AA) on 04 May 2007; and on 02 November 2007 she received an intramuscular right deltoid injection of FLUZONE (lot number U2436AA), and an intramuscular left arm (also documented as right arm in patient''s chart) injection of GARDASIL (manufacturer Merck, lot number unknown). The patient was in the physician''s office around 22 December 2010 and during her physical examination it was noted she had a 6 x 6.5 cm lump under the skin at the right deltoid. It was reported by the patient''s mother that the lump had been there since the patient''s last vaccinations 3-4 years ago. The event had not been reported to the physician prior to that time. Relevant medical history was unknown. Per the reporter, no relevant diagnostic tests/laboratory data were performed. Documents held by sender: None.

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