| VAERS ID: |
108799 (history) |
| Form: |
Version 1.0 |
| Age: |
0.3 |
| Sex: |
Male |
| Location: |
Washington |
| Vaccinated: | 1998-03-17 |
| Onset: | 1998-03-18 |
| Days after vaccination: | 1 |
| Submitted: |
1998-03-18 |
| Days after onset: | 0 |
| Entered: |
1998-03-24 |
| Days after submission: | 6 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES |
7B91821 / 2 |
LL / - |
| HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. |
1484E / 2 |
RL / - |
| IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. |
M1070 / 2 |
RL / SC |
Administered by: Private Purchased by: Public
Symptoms: Agitation,
Chills,
Oral candidiasis,
Otitis media,
Stupor,
Sudden infant death syndrome,
Unevaluable event
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Oropharyngeal infections (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Neonatal disorders (narrow), Hypoglycaemia (broad), Opportunistic infections (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 1998-03-18
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: Amox given 17MAR98;Nystatin oral susp
Current Illness: URI & OM
Preexisting Conditions: eczema & seborrhea dermatitis
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: pt found deceased in crib this AM <24hr p/vax; |
