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From the 11/26/2021 release of VAERS data:

This is VAERS ID 52579

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Case Details

VAERS ID: 52579 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Female  
Location: Tennessee  
Vaccinated:1993-04-15
Onset:1993-04-16
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 1993-05-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 2F41092 / UNK - / -
HEP: HEP B (FOREIGN) / MERCK & CO. INC. 1555V / UNK - / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M025JE / UNK - / -
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. G0083 / UNK - / -

Administered by: Unknown       Purchased by: Unknown
Symptoms: Apnoea, Bradycardia, Cardiac arrest, Haematemesis, Hypoventilation, Pallor
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Gastrointestinal haemorrhage (narrow), Acute central respiratory depression (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow), Infective pneumonia (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: APAP
Current Illness:
Preexisting Conditions: premature pt w/apnea of prematurity nearing discharge from hosp; NKA;
Allergies:
Diagnostic Lab Data: aminophylline;
CDC Split Type:

Write-up: pt became ashen, bradycardic, & hypoventilated; blood tinged vomitus was noted; pt was intubated & given CPR; pt did not respond to resuscitation & died; temporally related to vax administration (2hrs);


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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=52579


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