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This is VAERS ID 107036

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 107036
VAERS Form:
Age:1.4
Sex:Male
Location:Georgia
Vaccinated:1998-01-15
Onset:1998-01-20
Submitted:0000-00-00
Entered:1998-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: INFANRIX / SMITHKLINE 826A2 / - LL / IM
HIBV: HIBTITER / LEDERLE(PRAXIS) 1563E / - RL / IM
MMR: MMR II / MSD 1801E / - LA / SC

Administered by: Public      Purchased by: Unknown
Symptoms: BRAIN SYND ACUTE, CONVULS, CSF ABNORM, EDEMA BRAIN, ATAXIA

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1998-01-23
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: URI
Preexisting Conditions: mild atopic dermatitis noted on 15JAN98
Allergies:
Diagnostic Lab Data: CSF showed 37WBC, 0RBC, repeat CSF p/sz WBC 140, RBC 90;
CDC 'Split Type':

Write-up: pt presented to ER w/refusal to walk, ataxia, devel sz;required intubation during hosp;CT scan cerebral edema, herniation, death;

Changed on 12/8/2009

VAERS ID: 107036 Before After
VAERS Form:
Age:1.4
Sex:Male
Location:Georgia
Vaccinated:1998-01-15
Onset:1998-01-20
Submitted:0000-00-00
Entered:1998-01-29 1998-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: INFANRIX DTAP (INFANRIX) / SMITHKLINE SMITHKLINE BEECHAM 826A2 / - LL / IM
HIBV: HIBTITER HIB (HIBTITER) / LEDERLE(PRAXIS) LEDERLE PRAXSIS 1563E / - RL / IM
MMR: MMR II MEASLES + MUMPS + RUBELLA (MMR II) / MSD MERCK & CO. INC. 1801E / - LA / SC

Administered by: Public      Purchased by: Unknown Public
Symptoms: Convulsion, Coordination abnormal, Delirium, Hypokinesia, Hypoxia, Brain oedema, CSF test abnormal, BRAIN SYND ACUTE, CONVULS, CSF ABNORM, EDEMA BRAIN, ATAXIA

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1998-01-23
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: URI
Preexisting Conditions: mild atopic dermatitis noted on 15JAN98
Allergies:
Diagnostic Lab Data: CSF showed 37WBC, 0RBC, repeat CSF p/sz WBC 140, RBC 90;
CDC 'Split Type': (blank) GA98003

Write-up: pt presented to ER w/refusal to walk, ataxia, devel sz;required intubation during hosp;CT scan cerebral edema, herniation, death;

Changed on 5/14/2017

VAERS ID: 107036 Before After
VAERS Form:
Age:1.4
Sex:Male
Location:Georgia
Vaccinated:1998-01-15
Onset:1998-01-20
Submitted:0000-00-00
Entered:1998-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 826A2 / - LL / IM
HIBV: HIB (HIBTITER) / LEDERLE PRAXSIS PFIZER/WYETH 1563E / - RL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1801E / - LA / SC

Administered by: Public      Purchased by: Public
Symptoms: Convulsion, Coordination abnormal, Delirium, Hypokinesia, Hypoxia, Brain oedema, CSF test abnormal

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1998-01-23
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: URI
Preexisting Conditions: mild atopic dermatitis noted on 15JAN98
Allergies:
Diagnostic Lab Data: CSF showed 37WBC, 0RBC, repeat CSF p/sz WBC 140, RBC 90;
CDC 'Split Type': GA98003

Write-up: pt presented to ER w/refusal to walk, ataxia, devel sz;required intubation during hosp;CT scan cerebral edema, herniation, death;

Changed on 9/14/2017

VAERS ID: 107036 Before After
VAERS Form:(blank) 1
Age:1.4
Sex:Male
Location:Georgia
Vaccinated:1998-01-15
Onset:1998-01-20
Submitted:0000-00-00
Entered:1998-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 826A2 / - UNK LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 1563E / - UNK RL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1801E / - UNK LA / SC

Administered by: Public      Purchased by: Public
Symptoms: Convulsion, Coordination abnormal, Delirium, Hypokinesia, Hypoxia, Brain oedema, CSF test abnormal

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1998-01-23
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: URI
Preexisting Conditions: mild atopic dermatitis noted on 15JAN98
Allergies:
Diagnostic Lab Data: CSF showed 37WBC, 0RBC, repeat CSF p/sz WBC 140, RBC 90;
CDC 'Split Type': GA98003

Write-up: pt presented to ER w/refusal to walk, ataxia, devel sz;required intubation during hosp;CT scan cerebral edema, herniation, death;

Changed on 2/14/2018

VAERS ID: 107036 Before After
VAERS Form:1
Age:1.4
Sex:Male
Location:Georgia
Vaccinated:1998-01-15
Onset:1998-01-20
Submitted:0000-00-00
Entered:1998-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 826A2 / UNK LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 1563E / UNK RL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1801E / UNK LA / SC

Administered by: Public      Purchased by: Public
Symptoms: Convulsion, Coordination abnormal, Delirium, Hypokinesia, Hypoxia, Brain oedema, CSF test abnormal

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1998-01-23
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: URI
Preexisting Conditions: mild atopic dermatitis noted on 15JAN98
Allergies:
Diagnostic Lab Data: CSF showed 37WBC, 0RBC, repeat CSF p/sz WBC 140, RBC 90;
CDC 'Split Type': GA98003

Write-up: pt presented to ER w/refusal to walk, ataxia, devel sz;required intubation during hosp;CT scan cerebral edema, herniation, death;

Changed on 6/14/2018

VAERS ID: 107036 Before After
VAERS Form:1
Age:1.4
Sex:Male
Location:Georgia
Vaccinated:1998-01-15
Onset:1998-01-20
Submitted:0000-00-00
Entered:1998-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 826A2 / UNK LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 1563E / UNK RL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1801E / UNK LA / SC

Administered by: Public      Purchased by: Public
Symptoms: Convulsion, Coordination abnormal, Delirium, Hypokinesia, Hypoxia, Brain oedema, CSF test abnormal

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1998-01-23
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: URI
Preexisting Conditions: mild atopic dermatitis noted on 15JAN98
Allergies:
Diagnostic Lab Data: CSF showed 37WBC, 0RBC, repeat CSF p/sz WBC 140, RBC 90;
CDC 'Split Type': GA98003

Write-up: pt presented to ER w/refusal to walk, ataxia, devel sz;required intubation during hosp;CT scan cerebral edema, herniation, death;

Changed on 8/14/2018

VAERS ID: 107036 Before After
VAERS Form:1
Age:1.4
Sex:Male
Location:Georgia
Vaccinated:1998-01-15
Onset:1998-01-20
Submitted:0000-00-00
Entered:1998-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 826A2 / UNK LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 1563E / UNK RL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1801E / UNK LA / SC

Administered by: Public      Purchased by: Public
Symptoms: Convulsion, Coordination abnormal, Delirium, Hypokinesia, Hypoxia, Brain oedema, CSF test abnormal

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1998-01-23
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: URI
Preexisting Conditions: mild atopic dermatitis noted on 15JAN98
Allergies:
Diagnostic Lab Data: CSF showed 37WBC, 0RBC, repeat CSF p/sz WBC 140, RBC 90;
CDC 'Split Type': GA98003

Write-up: pt presented to ER w/refusal to walk, ataxia, devel sz;required intubation during hosp;CT scan cerebral edema, herniation, death;

Changed on 9/14/2018

VAERS ID: 107036 Before After
VAERS Form:1
Age:1.4
Sex:Male
Location:Georgia
Vaccinated:1998-01-15
Onset:1998-01-20
Submitted:0000-00-00
Entered:1998-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 826A2 / UNK LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 1563E / UNK RL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1801E / UNK LA / SC

Administered by: Public      Purchased by: Public
Symptoms: Convulsion, Coordination abnormal, Delirium, Hypokinesia, Hypoxia, Brain oedema, CSF test abnormal

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1998-01-23
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: URI
Preexisting Conditions: mild atopic dermatitis noted on 15JAN98
Allergies:
Diagnostic Lab Data: CSF showed 37WBC, 0RBC, repeat CSF p/sz WBC 140, RBC 90;
CDC 'Split Type': GA98003

Write-up: pt presented to ER w/refusal to walk, ataxia, devel sz;required intubation during hosp;CT scan cerebral edema, herniation, death;

Changed on 10/14/2018

VAERS ID: 107036 Before After
VAERS Form:1
Age:1.4
Sex:Male
Location:Georgia
Vaccinated:1998-01-15
Onset:1998-01-20
Submitted:0000-00-00
Entered:1998-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 826A2 / UNK LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 1563E / UNK RL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1801E / UNK LA / SC

Administered by: Public      Purchased by: Public
Symptoms: Convulsion, Coordination abnormal, Delirium, Hypokinesia, Hypoxia, Brain oedema, CSF test abnormal

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1998-01-23
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: URI
Preexisting Conditions: mild atopic dermatitis noted on 15JAN98
Allergies:
Diagnostic Lab Data: CSF showed 37WBC, 0RBC, repeat CSF p/sz WBC 140, RBC 90;
CDC 'Split Type': GA98003

Write-up: pt presented to ER w/refusal to walk, ataxia, devel sz;required intubation during hosp;CT scan cerebral edema, herniation, death;

Changed on 12/24/2020

VAERS ID: 107036 Before After
VAERS Form:1
Age:1.4
Sex:Male
Location:Georgia
Vaccinated:1998-01-15
Onset:1998-01-20
Submitted:0000-00-00
Entered:1998-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 826A2 / UNK LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 1563E / UNK RL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1801E / UNK LA / SC

Administered by: Public      Purchased by: Public
Symptoms: Convulsion, Coordination abnormal, Delirium, Hypokinesia, Hypoxia, Brain oedema, CSF test abnormal

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1998-01-23
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: URI
Preexisting Conditions: mild atopic dermatitis noted on 15JAN98
Allergies:
Diagnostic Lab Data: CSF showed 37WBC, 0RBC, repeat CSF p/sz WBC 140, RBC 90;
CDC 'Split Type': GA98003

Write-up: pt presented to ER w/refusal to walk, ataxia, devel sz;required intubation during hosp;CT scan cerebral edema, herniation, death;

Changed on 12/30/2020

VAERS ID: 107036 Before After
VAERS Form:1
Age:1.4
Sex:Male
Location:Georgia
Vaccinated:1998-01-15
Onset:1998-01-20
Submitted:0000-00-00
Entered:1998-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 826A2 / UNK LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 1563E / UNK RL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1801E / UNK LA / SC

Administered by: Public      Purchased by: Public
Symptoms: Convulsion, Coordination abnormal, Delirium, Hypokinesia, Hypoxia, Brain oedema, CSF test abnormal

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1998-01-23
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: URI
Preexisting Conditions: mild atopic dermatitis noted on 15JAN98
Allergies:
Diagnostic Lab Data: CSF showed 37WBC, 0RBC, repeat CSF p/sz WBC 140, RBC 90;
CDC 'Split Type': GA98003

Write-up: pt presented to ER w/refusal to walk, ataxia, devel sz;required intubation during hosp;CT scan cerebral edema, herniation, death;

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