| VAERS ID: |
110712 (history) |
| Form: |
Version 1.0 |
| Age: |
23.0 |
| Sex: |
Male |
| Location: |
Massachusetts |
| Vaccinated: | 1998-01-15 |
| Onset: | 1998-01-30 |
| Days after vaccination: | 15 |
| Submitted: |
1998-05-05 |
| Days after onset: | 94 |
| Entered: |
1998-05-11 |
| Days after submission: | 6 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| TD: TD ADSORBED (NO BRAND NAME) / MASS. PUB HLTH BIOL LAB |
TD61 / UNK |
- / - |
Administered by: Private Purchased by: Other
Symptoms: Condition aggravated,
Convulsion
SMQs:, Systemic lupus erythematosus (broad), Convulsions (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Generalised convulsive seizures following immunisation (narrow), Hypoglycaemia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 1998-01-30
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Dilantin;Tegretol
Current Illness: Epilepsy
Preexisting Conditions: epilepsy
Allergies:
Diagnostic Lab Data: medical autopsy found no other abnormalities. The autopsy report states seizure disorder.
CDC Split Type:
Write-up: 14 days p/vax pt died of sz disorder;had 2yr hx of sz, most recently determined to be epilepsy. The autopsy report states seizure disorder. | 