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This is VAERS ID 442402

Case Details

VAERS ID: 442402 (history)  
Age: 15.0  
Gender: Male  
Location: Oregon  
Vaccinated:2011-10-17
Onset:2011-10-17
   Days after vaccination:0
Submitted: 2011-11-14
   Days after onset:28
Entered: 2011-11-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 1262AA / - RA / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U4006AA / - RA / IM
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS AC52B072EA / - RA / IM

Administered by: Private       Purchased by: Public
Symptoms: Death, Pain, Swelling
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Haemodynamic oedema, effusions and fluid overload (narrow)

Life Threatening? No
Died? Yes
   Date died: 2011-10-20
   Days after onset: 3
Permanent Disability? No
Recovered? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Depakote, Lyrica, Diazapam, Adderall
Current Illness: No
Preexisting Conditions: Seizure Disorder
Diagnostic Lab Data:
CDC Split Type:

Write-up: Initial soreness and swelling. Death 10/20/2011.


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