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This is VAERS ID 107005

(NOTE: This result is from the 10/14/2018 version of the VAERS database)

Case Details

VAERS ID: 107005 (history)  
Form: Version 1.0  
Age: 12.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:1998-01-13
Onset:1998-01-13
   Days after vaccination:0
Submitted: 1998-01-20
   Days after onset:7
Entered: 1998-01-27
   Days after submission:7
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES 6F81441 / 4 LA / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1238D / 2 RA / SC
PPV: PNEUMO (PNU-IMUNE) / PFIZER/WYETH 441228 / 4 MO / PO

Administered by: Private       Purchased by: Public
Symptoms: 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: 1998-01-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: Risperdal;wellbutin
Current Illness: OM
Preexisting Conditions: NKDA;obesity, depression
Allergies:
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: pt reportedly collapsed @ home suddenly


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Link To This Search Result:

https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20181014&IDNUMBER=107005


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