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This is VAERS ID 94040

Case Details

VAERS ID: 94040 (history)  
Form: Version 1.0  
Age: 1.0  
Sex: Male  
Location: Alabama  
Vaccinated:1996-12-27
Onset:1996-12-29
   Days after vaccination:2
Submitted: 1997-01-07
   Days after onset:9
Entered: 1997-01-27
   Days after submission:20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 436789 / 4 LL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0731D / 1 LA / SC

Administered by: Public       Purchased by: Public
Symptoms: Asthma, Cough, Ear disorder, Infection, Otitis media, Pyrexia, Rhinitis, Sudden infant death syndrome
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Eosinophilic pneumonia (broad), Neonatal disorders (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-12-29
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: ear infection; minimal wheezing
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type: AL9628

Write-up: pt recv vax & temp99.4R;on exam, noted TM''s red full;productive cough, minimal wheezing, mucoid nasal discharge;referred to ER;seen in ER same day;t100.8 R:for ear infect & released;to ER 29DEC96 DOA:;pt died for SIDS;


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