| VAERS ID: |
120450 (history) |
| Form: |
Version 1.0 |
| Age: |
1.0 |
| Sex: |
Female |
| Location: |
Alabama |
| Vaccinated: | 1999-03-10 |
| Onset: | 1999-03-13 |
| Days after vaccination: | 3 |
| Submitted: |
1999-03-18 |
| Days after onset: | 5 |
| Entered: |
1999-03-19 |
| Days after submission: | 1 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM |
865A2 / 3 |
LL / IM |
| HIBV: HIB (HIBTITER) / PFIZER/WYETH |
361453 / 3 |
RL / IM |
| MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. |
0734E / 1 |
LL / SC |
| OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH |
79413 / 3 |
MO / PO |
| VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. |
10524 / 1 |
LA / SC |
Administered by: Public Purchased by: Public
Symptoms: Apnoea,
Bronchiolitis,
Cardiac arrest,
Hepatomegaly,
Laboratory test abnormal,
Lymphadenopathy,
Myocarditis,
Neoplasm,
Pneumonia,
Pyrexia,
Splenomegaly,
Vaginal haemorrhage,
Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Liver related investigations, signs and symptoms (narrow), Anaphylactic reaction (broad), Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Non-haematological tumours of unspecified malignancy (narrow), Infective pneumonia (narrow)
Life Threatening? Yes
Birth Defect? No
Died? Yes
Date died: 1999-03-13
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: lt lung culture:Viridans Streptococcus, 2 colonies Candida, Haemophilus, beta lactamase+; rt lung culture: haemophilus, beta lactamase+; Blood culture: Staphylococcus epidermidis
CDC Split Type: AL9904
Write-up: hx of pt arriving in ER in full arrest & expired @ hosp;sl bloody vaginal discharge noted in ER; |
