| VAERS ID: |
545049 (history) |
| Form: |
Version 1.0 |
| Age: |
0.17 |
| Gender: |
Male |
| Location: |
New York |
| Vaccinated: | 2014-08-26 |
| Onset: | 2014-09-12 |
| Days after vaccination: | 17 |
| Submitted: |
2014-09-18 |
| Days after onset: | 6 |
| Entered: |
2014-09-24 |
| Days after submission: | 6 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR |
C4724AA / 1 |
LL / IM |
| PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH |
H65735 / 1 |
RL / IM |
| RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS |
A41FB434A / 1 |
MO / PO |
Administered by: Private Purchased by: Private
Symptoms: Crying,
Death,
Disseminated intravascular coagulation,
Dyspnoea,
Enema administration,
Food intolerance,
Haematochezia,
Intussusception,
Irritability,
Lethargy,
Shock,
Ultrasound abdomen abnormal
SMQs:, Anaphylactic reaction (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Hypovolaemic shock conditions (narrow), Toxic-septic shock conditions (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypoglycaemic and neurogenic shock conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Gastrointestinal obstruction (narrow), Gastrointestinal haemorrhage (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Ischaemic colitis (broad), Cardiomyopathy (broad), Depression (excl suicide and self injury) (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (narrow), Hypoglycaemia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2014-09-15
Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Hyoscyamine sulfate prescribed 9/12/14
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Abdominal US 9/14/14 confirmed intussusception
CDC Split Type:
Write-up: Fussiness and crying onset 9/12/14 early AM, blood in stool that AM. More lethargic 9/13/14, not tolerating feeds. Seen in Emergency Room 9/13/14 - 9/14/14 - diagnosed with right upper quadrant intussusception reduced with air enema. Symptoms of shock, disseminated intravascular coagulation, third spacing of fluid, difficulty ventilating and ultimate death on 9/15/14. |
