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This is VAERS ID 441799

Case Details

VAERS ID: 441799 (history)  
Form: Version 1.0  
Age: 0.31  
Gender: Male  
Location: Kansas  
Vaccinated:2011-10-28
Onset:2011-11-01
   Days after vaccination:4
Submitted: 2011-11-08
   Days after onset:7
Entered: 2011-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B300AA / 2 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH266AA / 2 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 9163113 / 2 LL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41CB206A / 2 MO / PO

Administered by: Private       Purchased by: Other
Symptoms: Hypophagia, Intussusception, Irritability, Ultrasound abdomen abnormal
SMQs:, Retroperitoneal fibrosis (broad), Gastrointestinal obstruction (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Hypoglycaemia (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, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Prevacid
Current Illness: None
Preexisting Conditions: Laryngomalacia Gastroesophageal reflux Pulmonic valve stenosis and peripheral pulmonary stenosis
Allergies:
Diagnostic Lab Data: Bedside ultrasound on 11/7/11 showed ''doughnut'' sign consistent with intussusception. Subsequent ultrasound on 11/7/11 no longer showed ''doughnut'' sign.
CDC Split Type:

Write-up: Intermittent episodes of increased fussiness, drawing up of legs, decreased oral intake. Evaluated in the Emergency Department where an bedside ultrasound showed sign of intussusception. Subsequent ultrasound when not fussy did not show evidence of intussusception (thus it spontaneously resolved without intervention).


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