| VAERS ID: |
75868 (history) |
| Form: |
Version 1.0 |
| Age: |
37.0 |
| Sex: |
Male |
| Location: |
Maryland |
| Vaccinated: | 1995-05-25 |
| Onset: | 1995-06-18 |
| Days after vaccination: | 24 |
| Submitted: |
1995-07-11 |
| Days after onset: | 23 |
| Entered: |
1995-07-13 |
| Days after submission: | 2 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| HEPA: HEP A (HAVRIX) / SMITHKLINE BEECHAM |
425A6 / UNK |
LA / - |
| MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. |
659A / UNK |
RA / SC |
| TD: TD ADSORBED (NO BRAND NAME) / CONNAUGHT LABORATORIES |
4E61168 / UNK |
RA / - |
Administered by: Public Purchased by: Unknown
Symptoms: Encephalitis,
Herpes zoster
SMQs:, Noninfectious encephalitis (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad)
Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC Split Type: MD95025
Write-up: pt recv vax; devel shingles on 18jun95;dx w/ encephalitis; adm to hosp;felt vax rxn;discharged 29jun95 | 