VAERS ID: |
570801 (history) |
Form: |
Version 1.0 |
Age: |
16.0 |
Sex: |
Female |
Location: |
Virginia |
Vaccinated: | 2013-06-01 |
Onset: | 2014-10-10 |
Days after vaccination: | 496 |
Submitted: |
2015-03-22 |
Days after onset: | 163 |
Entered: |
2015-03-22 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
HPV4: HPV (GARDASIL) / MERCK & CO. INC. |
- / UNK |
AR / SYR |
Administered by: Unknown Purchased by: Private Symptoms: Death,
Syncope SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2014-10-11
Days after onset: 1
Permanent Disability? No
Recovered? No Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Other Medications: Current Illness: None Preexisting Conditions: None Allergies: Diagnostic Lab Data: CDC Split Type:
Write-up: Syncope. Died at ER. |