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From the 12/8/2009 release of VAERS data (an older release, current is 6/11/2021):

This is VAERS ID 133412



Case Details

VAERS ID: 133412 (history)  
Form: Version .0  
Age: 0.2  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2000-01-03
Onset:2000-01-06
   Days after vaccination:3
Submitted: 2000-01-12
   Days after onset:6
Entered: 2000-01-21
   Days after submission:9
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES 7387AA / 0 RL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1527J / 0 LL / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES UA462AB / 0 LL / IM
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. N04911 / 0 RL / SC

Administered by: Private       Purchased by: Public
Symptoms: Apnoea, Convulsion, Cyanosis, Hypotonia, Hypoxia, Skin discolouration, Stupor
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Peripheral neuropathy (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Convulsions (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: LP-normal, CT scan - slight promonence of ventricles, EEG - normal
CDC Split Type:

Write-up: Pt developed episodes of cyanosis associated with apnea, low O2 sats and staring, limpness - dx seizures seen in ER on 1/8/00, parents stated some blueness around lips noted 36 hrs before being seen.


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Link To This Search Result:

https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20091208&IDNUMBER=133412


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