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From the 10/14/2018 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 1.0  
Age: 0.17  
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 / 1 RL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1527J / 1 LL / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES UA462AB / 1 LL / IM
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX CONNAUGHT N0491 / 1 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), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (narrow), Respiratory failure (narrow), Hypoglycaemia (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
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=20181014&IDNUMBER=133412


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