| VAERS ID: |
457250 (history) |
| Form: |
Version 1.0 |
| Age: |
0.18 |
| Gender: |
Female |
| Location: |
Connecticut |
| Vaccinated: | 2012-04-11 |
| Onset: | 2012-06-01 |
| Days after vaccination: | 51 |
| Submitted: |
2012-06-05 |
| Days after onset: | 4 |
| Entered: |
2012-06-12 |
| Days after submission: | 7 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR |
C4131AA / 1 |
RL / IM |
| HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS |
AHBVC090FA / 2 |
RL / IM |
| PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH |
917245 / 1 |
LL / IM |
| RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS |
A41FB210A / 1 |
MO / PO |
Administered by: Other Purchased by: Other
Symptoms: Barium enema,
Barium enema abnormal,
Intestinal obstruction,
Intussusception,
Surgery,
X-ray abnormal
SMQs:, Pseudomembranous colitis (broad), Gastrointestinal obstruction (narrow), Ischaemic colitis (broad)
Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 10 days
Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: XRay barium enema confirming diagnosis
CDC Split Type:
Write-up: Intestinal obstruction -$g intussusception. Required surgery. Pt admitted to hospital. |
