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This is VAERS ID 419174

Case Details

VAERS ID: 419174 (history)  
Form: Version 1.0  
Age: 15.0  
Sex: Female  
Location: Foreign  
   Days after vaccination:3
Submitted: 2011-03-18
   Days after onset:162
Entered: 2011-03-21
   Days after submission:3
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Unknown       Purchased by: Unknown
Symptoms: Cardiac disorder, Condition aggravated, Cough, Death, Haemoptysis, Malaise, Renal disorder
SMQs:, Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2010-11-03
   Days after onset: 27
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Unknown
Diagnostic Lab Data: Unknown
CDC Split Type: WAES1103USA00922

Write-up: Information has been received from a physician concerning a 15 year old female patient with longstanding health problems (according to mother) since childhood who on 04-OCT-2010 was vaccinated IM with a second dose of GARDASIL (Lot# not reported). In September 2010, the patient experienced cough and was sick. On 07-OCT-2010, the patient experienced cough and haemoptysis. On 30-OCT-2010, the patient was diagnosed with kidney "problem" and heart "problem". The patient was admitted to hospital. The patient''s mother cannot recall treatment or hospital ID number and had not kept files. On 03-NOV-2010, the patient died. The cause of death was not reported. Cough, sickness, haemoptysis, kidney "problem" and heart "problem" were considered to be immediately life-threatening by the reporter.

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