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This is VAERS ID 113718

(NOTE: This result is from the 5/14/2017 version of the VAERS database)

Case Details

VAERS ID: 113718 (history)  
Form: Version .0  
Age: 0.4  
Sex: Male  
Location: Pennsylvania  
Vaccinated:1998-07-15
Onset:1998-07-15
   Days after vaccination:0
Submitted: 1998-08-27
   Days after onset:43
Entered: 1998-08-31
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES 0925880 / 1 LL / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES 094642 / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N02912 / 1 RL / IM

Administered by: Private       Purchased by: Private
Symptoms: Agitation, Apnoea, Cardiac arrest
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Acute central respiratory depression (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Cardiomyopathy (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1998-07-19
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness:
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: pt reported to have been mildly irritable the day & the day p/vax;on the 4th day p/vax pt had bottle in AM (8AM) & was put down for a nap around noon & was found dead about 30min later;


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https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20170514&IDNUMBER=113718


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