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This is VAERS ID 57571

Case Details

VAERS ID: 57571 (history)  
Form: Version 1.0  
Age: 1.4  
Sex: Male  
Location: Georgia  
Vaccinated:1993-07-27
Onset:0000-00-00
Submitted: 1993-09-28
Entered: 1993-11-22
   Days after submission:55
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES 3G41024 / 1 LL / IM
HIBV: HIB (PROHIBIT) / CONNAUGHT LABORATORIES 2J41090 / 1 RL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1508V / 1 RL / SC
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 678E1 / 3 MO / PO

Administered by: Unknown       Purchased by: Unknown
Symptoms: Agitation, Ascites, Cardiomegaly, Infection, Myocarditis, Necrosis, Pericardial effusion, Rhinitis
SMQs:, Cardiac failure (broad), Liver related investigations, signs and symptoms (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Acute pancreatitis (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1993-08-14
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type: GA93193

Write-up: NONE reported to hlth center; TARS: pt had fussiness & runny nose for a day or 2 prior to death; pt went into sudden arrest;


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