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This is VAERS ID 485757

History of Changes from the VAERS Wayback Machine

First Appeared on 3/12/2013

VAERS ID: 485757
VAERS Form:
Age:11.0
Sex:Female
Location:New York
Vaccinated:2013-02-19
Onset:2013-02-19
Submitted:2013-02-25
Entered:2013-02-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS AHAVB677CA / - UN / UN
HPV4: HPV (GARDASIL) / MERCK & CO. INC. H016238 / - UN / UN
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U42927 / - UN / UN
TDAP: TDAP (ADACEL) / SANOFI PASTEUR U4431BA / - UN / UN

Administered by: Private      Purchased by: Unknown
Symptoms: Cardiac arrest, Crying, Death, Respiratory arrest, Skin discolouration, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-02-20
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: DILANTIN; Phenobarb
Current Illness: Medical record - cough - resp sym x 5 days (doc denies)
Preexisting Conditions: Microcephaly; seizure
Allergies:
Diagnostic Lab Data: See reverse
CDC 'Split Type':

Write-up: 2/19/13 23:24 Pt brought in by ambulance in cardiac arrest, "mother states pt has been having cough & URI symptoms since 5 days - seen by doctor 2/19/13 & given 4 vaccines. Pt sleeping & crying - suddenly pt turned white & was not breathing - 911 called & intubated. Doctor states he was not aware of any illness & child''s DILANTIN level was 1.0. No lab found in medical record child revived & transfer to another hospital where child died on 2/20/13.


Changed on 9/17/2013

VAERS ID: 485757 Before After
VAERS Form:
Age:11.0
Sex:Female
Location:New York
Vaccinated:2013-02-19
Onset:2013-02-19
Submitted:2013-02-25
Entered:2013-02-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS AHAVB677CA / - UN / UN
HPV4: HPV (GARDASIL) / MERCK & CO. INC. H016238 / - UN / UN
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U42927 / - UN / UN
TDAP: TDAP (ADACEL) / SANOFI PASTEUR U4431BA / - UN / UN

Administered by: Private      Purchased by: Unknown
Symptoms: Alanine aminotransferase increased, Areflexia, Aspartate aminotransferase increased, Atelectasis, Blood calcium decreased, Blood chloride decreased, Blood gases abnormal, Blood glucose increased, Blood magnesium decreased, Blood potassium decreased, Carbon dioxide decreased, Cardiac arrest, Chest X-ray abnormal, Computerised tomogram abnormal, Crying, Culture urine positive, Cyanosis, Death, Diabetes insipidus, Electroencephalogram abnormal, Epilepsy, Glucose urine present, Gram stain positive, Mydriasis, Pleural effusion, Pupil fixed, Pyrexia, Red blood cells urine positive, Respiratory arrest, Resuscitation, Skin discolouration, Tremor, Unresponsive to stimuli, White blood cells urine positive, Brain death, Drug screen positive, Blood phosphorus decreased, Blood bilirubin decreased, Urine leukocyte esterase positive, Nitrite urine present, Sputum culture positive, Protein urine present, Computerised tomogram head, Urine ketone body present, Blood alkaline phosphatase increased, Mechanical ventilation, Endotracheal intubation, Brain injury, Escherichia test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-02-20
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: DILANTIN; Phenobarb
Current Illness: Medical record - cough - resp sym x 5 days (doc denies) The following information was obtained through follow-up and/or provided by the government. 8/26/13: Viral URI.
Preexisting Conditions: Microcephaly; seizure The following information was obtained through follow-up and/or provided by the government. 4/15/30 PMH: Congenital hydrocephalus with VP shunt. GDD and g-tube dependent. Global Developmental Delay. Seizure disorder.
Allergies:
Diagnostic Lab Data: See reverse The following information was obtained through follow-up and/or provided by the government. 8/26/13 Representative Labs and Diagnostics: CHEM - Potassium 3.4 mmol/l (L) Chloride 116 mmol/l (H) CO2 15 mmol/l (L) Glucose 460 mg/dl (H) Calcium Total 6.8 mg/dl (L) Phosphorus 1.1 mg/dl (L) Magnesium 1.3 mg/dl (L) Bilirubin 0.1 mg/dl (L) Alk Phos 409 U/L (H) AST 556 U/L (H) ALT 342 U/L (H). Abnormal Arterial Blood Gases. Urinalysis - Glucose 1000, Ketone trace, Blood moderate, Protein 300, Nitrite (+), Leuk Est small, RBC 5-10 /hpf, WBC 5-10 /hpf. Drug Screen Urine - Barbiturates (+). Urine Culture (+) for E coli. Sputum Gram Stain (+) for several organisms, normal flora. Chest X-ray - Abnormal, atelectasis, pleural effusion. CT Head
CDC 'Split Type':

Write-up: 2/19/13 23:24 Pt brought in by ambulance in cardiac arrest, "mother states pt has been having cough & URI symptoms since 5 days - seen by doctor 2/19/13 & given 4 vaccines. Pt sleeping & crying - suddenly pt turned white & was not breathing - 911 called & intubated. Doctor states he was not aware of any illness & child''s DILANTIN level was 1.0. No lab found in medical record child revived & transfer to another hospital where child died on 2/20/13. The following information was obtained through follow-up and/or provided by the government. 8/19/13 Death Certificate received. Final Cause of Death: Anoxic brain death, due to Epilepsy (non traumatic), due to congenital hydrocephalus. 8/26/13 Hospital records and discharge summary received. Service date 2/20/13. Diagnosis: Brainstem death. Patient presents in cardiac arrest. Earlier relative noted head shaking and perioral cyanosis; no respiratory effort seen by EMS, asystole. CPR, intubated, at ED spontaneous sinus rhythm obtained and postresusitation care initiated. Transfered to hygher level facility and placed on mechanical ventilator. Fever. Developed diabetes insipidus, vasopressin drip initiated. Unresponsive, pupils fixed and dilated, no reflexes illicited. No cortical or brainstem activity, brainstem death declared. 4/15/30 Discharge summary received. No information abstracted.


Changed on 3/14/2015

VAERS ID: 485757 Before After
VAERS Form:
Age:11.0
Sex:Female
Location:New York
Vaccinated:2013-02-19
Onset:2013-02-19
Submitted:2013-02-25
Entered:2013-02-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS AHAVB677CA / - UN / UN
HPV4: HPV (GARDASIL) / MERCK & CO. INC. H016238 / - UN / UN
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U42927 / - UN / UN
TDAP: TDAP (ADACEL) / SANOFI PASTEUR U4431BA / - UN / UN

Administered by: Private      Purchased by: Unknown
Symptoms: Alanine aminotransferase increased, Areflexia, Aspartate aminotransferase increased, Atelectasis, Blood calcium decreased, Blood chloride decreased, Blood gases abnormal, Blood glucose increased, Blood magnesium decreased, Blood potassium decreased, Carbon dioxide decreased, Cardiac arrest, Chest X-ray abnormal, Computerised tomogram abnormal, Crying, Culture urine positive, Cyanosis, Death, Diabetes insipidus, Electroencephalogram abnormal, Epilepsy, Glucose urine present, Gram stain positive, Mydriasis, Pleural effusion, Pupil fixed, Pyrexia, Red blood cells urine positive, Respiratory arrest, Resuscitation, Skin discolouration, Tremor, Unresponsive to stimuli, White blood cells urine positive, Brain death, Drug screen positive, Blood phosphorus decreased, Blood bilirubin decreased, Urine leukocyte esterase positive, Nitrite urine present, Sputum culture positive, Protein urine present, Computerised tomogram head, Urine ketone body present, Blood alkaline phosphatase increased, Mechanical ventilation, Endotracheal intubation, Brain injury, Escherichia test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-02-20
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: DILANTIN; Phenobarb
Current Illness: Medical record - cough - resp sym x 5 days (doc denies) The following information was obtained through follow-up and/or provided by the government. 8/26/13: Viral URI.
Preexisting Conditions: Microcephaly; seizure The following information was obtained through follow-up and/or provided by the government. 4/15/30 PMH: Congenital hydrocephalus with VP shunt. GDD and g-tube dependent. Global Developmental Delay. Seizure disorder.
Allergies:
Diagnostic Lab Data: See reverse The following information was obtained through follow-up and/or provided by the government. 8/26/13 Representative Labs and Diagnostics: CHEM - Potassium 3.4 mmol/l (L) Chloride 116 mmol/l (H) CO2 15 mmol/l (L) Glucose 460 mg/dl (H) Calcium Total 6.8 mg/dl (L) Phosphorus 1.1 mg/dl (L) Magnesium 1.3 mg/dl (L) Bilirubin 0.1 mg/dl (L) Alk Phos 409 U/L (H) AST 556 U/L (H) ALT 342 U/L (H). Abnormal Arterial Blood Gases. Urinalysis - Glucose 1000, Ketone trace, Blood moderate, Protein 300, Nitrite (+), Leuk Est small, RBC 5-10 /hpf, WBC 5-10 /hpf. Drug Screen Urine - Barbiturates (+). Urine Culture (+) for E coli. Sputum Gram Stain (+) for several organisms, normal flora. Chest X-ray - Abnormal, atelectasis, pleural effusion. CT Head
CDC 'Split Type':

Write-up: 2/19/13 23:24 Pt brought in by ambulance in cardiac arrest, "mother states pt has been having cough & URI symptoms since 5 days - seen by doctor 2/19/13 & given 4 vaccines. Pt sleeping & crying - suddenly pt turned white & was not breathing - 911 called & intubated. Doctor states he was not aware of any illness & child''s DILANTIN level was 1.0. No lab found in medical record child revived & transfer to another hospital where child died on 2/20/13. The following information was obtained through follow-up and/or provided by the government. 8/19/13 Death Certificate received. Final Cause of Death: Anoxic brain death, due to Epilepsy (non traumatic), due to congenital hydrocephalus. 8/26/13 Hospital records and discharge summary received. Service date 2/20/13. Diagnosis: Brainstem death. Patient presents in cardiac arrest. Earlier relative noted head shaking and perioral cyanosis; no respiratory effort seen by EMS, asystole. CPR, intubated, at ED spontaneous sinus rhythm obtained and postresusitation care initiated. Transfered to hygher level facility and placed on mechanical ventilator. Fever. Developed diabetes insipidus, vasopressin drip initiated. Unresponsive, pupils fixed and dilated, no reflexes illicited. No cortical or brainstem activity, brainstem death declared. 4/15/30 Discharge summary received. No information abstracted.


Changed on 9/14/2017

VAERS ID: 485757 Before After
VAERS Form:(blank) 1
Age:11.0
Sex:Female
Location:New York
Vaccinated:2013-02-19
Onset:2013-02-19
Submitted:2013-02-25
Entered:2013-02-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS AHAVB677CA / - UNK UN / UN
HPV4: HPV (GARDASIL) / MERCK & CO. INC. H016238 / - UNK UN / UN
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U42927 / - UNK UN / UN
TDAP: TDAP (ADACEL) / SANOFI PASTEUR U4431BA / - UNK UN / UN

Administered by: Private      Purchased by: Unknown
Symptoms: Cardiac arrest, Crying, Death, Respiratory arrest, Skin discolouration, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-02-20
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: DILANTIN; Phenobarb
Current Illness: Medical record - cough - resp sym x 5 days (doc denies)
Preexisting Conditions: Microcephaly; seizure
Allergies:
Diagnostic Lab Data: See reverse
CDC 'Split Type':

Write-up: 2/19/13 23:24 Pt brought in by ambulance in cardiac arrest, "mother states pt has been having cough & URI symptoms since 5 days - seen by doctor 2/19/13 & given 4 vaccines. Pt sleeping & crying - suddenly pt turned white & was not breathing - 911 called & intubated. Doctor states he was not aware of any illness & child''s DILANTIN level was 1.0. No lab found in medical record child revived & transfer to another hospital where child died on 2/20/13.


Changed on 2/14/2018

VAERS ID: 485757 Before After
VAERS Form:1
Age:11.0
Sex:Female
Location:New York
Vaccinated:2013-02-19
Onset:2013-02-19
Submitted:2013-02-25
Entered:2013-02-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS AHAVB677CA / UNK UN / UN
HPV4: HPV (GARDASIL) / MERCK & CO. INC. H016238 / UNK UN / UN
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U42927 / UNK UN / UN
TDAP: TDAP (ADACEL) / SANOFI PASTEUR U4431BA / UNK UN / UN

Administered by: Private      Purchased by: Unknown
Symptoms: Cardiac arrest, Crying, Death, Respiratory arrest, Skin discolouration, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-02-20
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: DILANTIN; Phenobarb
Current Illness: Medical record - cough - resp sym x 5 days (doc denies)
Preexisting Conditions: Microcephaly; seizure
Allergies:
Diagnostic Lab Data: See reverse
CDC 'Split Type':

Write-up: 2/19/13 23:24 Pt brought in by ambulance in cardiac arrest, "mother states pt has been having cough & URI symptoms since 5 days - seen by doctor 2/19/13 & given 4 vaccines. Pt sleeping & crying - suddenly pt turned white & was not breathing - 911 called & intubated. Doctor states he was not aware of any illness & child''s DILANTIN level was 1.0. No lab found in medical record child revived & transfer to another hospital where child died on 2/20/13.


Changed on 6/14/2018

VAERS ID: 485757 Before After
VAERS Form:1
Age:11.0
Sex:Female
Location:New York
Vaccinated:2013-02-19
Onset:2013-02-19
Submitted:2013-02-25
Entered:2013-02-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS AHAVB677CA / UNK UN / UN
HPV4: HPV (GARDASIL) / MERCK & CO. INC. H016238 / UNK UN / UN
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U42927 / UNK UN / UN
TDAP: TDAP (ADACEL) / SANOFI PASTEUR U4431BA / UNK UN / UN

Administered by: Private      Purchased by: Unknown
Symptoms: Cardiac arrest, Crying, Death, Respiratory arrest, Skin discolouration, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-02-20
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: DILANTIN; Phenobarb
Current Illness: Medical record - cough - resp sym x 5 days (doc denies)
Preexisting Conditions: Microcephaly; seizure
Allergies:
Diagnostic Lab Data: See reverse
CDC 'Split Type':

Write-up: 2/19/13 23:24 Pt brought in by ambulance in cardiac arrest, "mother states pt has been having cough & URI symptoms since 5 days - seen by doctor 2/19/13 & given 4 vaccines. Pt sleeping & crying - suddenly pt turned white & was not breathing - 911 called & intubated. Doctor states he was not aware of any illness & child''s DILANTIN level was 1.0. No lab found in medical record child revived & transfer to another hospital where child died on 2/20/13.


Changed on 8/14/2018

VAERS ID: 485757 Before After
VAERS Form:1
Age:11.0
Sex:Female
Location:New York
Vaccinated:2013-02-19
Onset:2013-02-19
Submitted:2013-02-25
Entered:2013-02-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS AHAVB677CA / UNK UN / UN
HPV4: HPV (GARDASIL) / MERCK & CO. INC. H016238 / UNK UN / UN
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U42927 / UNK UN / UN
TDAP: TDAP (ADACEL) / SANOFI PASTEUR U4431BA / UNK UN / UN

Administered by: Private      Purchased by: Unknown
Symptoms: Cardiac arrest, Crying, Death, Respiratory arrest, Skin discolouration, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-02-20
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: DILANTIN; Phenobarb
Current Illness: Medical record - cough - resp sym x 5 days (doc denies)
Preexisting Conditions: Microcephaly; seizure
Allergies:
Diagnostic Lab Data: See reverse
CDC 'Split Type':

Write-up: 2/19/13 23:24 Pt brought in by ambulance in cardiac arrest, "mother states pt has been having cough & URI symptoms since 5 days - seen by doctor 2/19/13 & given 4 vaccines. Pt sleeping & crying - suddenly pt turned white & was not breathing - 911 called & intubated. Doctor states he was not aware of any illness & child''s DILANTIN level was 1.0. No lab found in medical record child revived & transfer to another hospital where child died on 2/20/13.


Changed on 9/14/2018

VAERS ID: 485757 Before After
VAERS Form:1
Age:11.0
Sex:Female
Location:New York
Vaccinated:2013-02-19
Onset:2013-02-19
Submitted:2013-02-25
Entered:2013-02-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS AHAVB677CA / UNK UN / UN
HPV4: HPV (GARDASIL) / MERCK & CO. INC. H016238 / UNK UN / UN
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U42927 / UNK UN / UN
TDAP: TDAP (ADACEL) / SANOFI PASTEUR U4431BA / UNK UN / UN

Administered by: Private      Purchased by: Unknown
Symptoms: Cardiac arrest, Crying, Death, Respiratory arrest, Skin discolouration, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-02-20
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: DILANTIN; Phenobarb
Current Illness: Medical record - cough - resp sym x 5 days (doc denies)
Preexisting Conditions: Microcephaly; seizure
Allergies:
Diagnostic Lab Data: See reverse
CDC 'Split Type':

Write-up: 2/19/13 23:24 Pt brought in by ambulance in cardiac arrest, "mother states pt has been having cough & URI symptoms since 5 days - seen by doctor 2/19/13 & given 4 vaccines. Pt sleeping & crying - suddenly pt turned white & was not breathing - 911 called & intubated. Doctor states he was not aware of any illness & child''s DILANTIN level was 1.0. No lab found in medical record child revived & transfer to another hospital where child died on 2/20/13.


Changed on 10/14/2018

VAERS ID: 485757 Before After
VAERS Form:1
Age:11.0
Sex:Female
Location:New York
Vaccinated:2013-02-19
Onset:2013-02-19
Submitted:2013-02-25
Entered:2013-02-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS AHAVB677CA / UNK UN / UN
HPV4: HPV (GARDASIL) / MERCK & CO. INC. H016238 / UNK UN / UN
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U42927 / UNK UN / UN
TDAP: TDAP (ADACEL) / SANOFI PASTEUR U4431BA / UNK UN / UN

Administered by: Private      Purchased by: Unknown
Symptoms: Cardiac arrest, Crying, Death, Respiratory arrest, Skin discolouration, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-02-20
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: DILANTIN; Phenobarb
Current Illness: Medical record - cough - resp sym x 5 days (doc denies)
Preexisting Conditions: Microcephaly; seizure
Allergies:
Diagnostic Lab Data: See reverse
CDC 'Split Type':

Write-up: 2/19/13 23:24 Pt brought in by ambulance in cardiac arrest, "mother states pt has been having cough & URI symptoms since 5 days - seen by doctor 2/19/13 & given 4 vaccines. Pt sleeping & crying - suddenly pt turned white & was not breathing - 911 called & intubated. Doctor states he was not aware of any illness & child''s DILANTIN level was 1.0. No lab found in medical record child revived & transfer to another hospital where child died on 2/20/13.

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