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This is VAERS ID 133476

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 133476
VAERS Form:
Age:0.3
Sex:Male
Location:Alabama
Vaccinated:2000-01-19
Onset:2000-01-19
Submitted:2000-01-24
Entered:2000-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: ACEL-IMUNE / LEDERLE 467012 / 1 LL / IM
HIBV: HIBTITER / LEDERLE(PRAXIS) 570403A / 1 RL / IM
IPV: IPV / MERIEUX INST P0998 / 1 LL / SC

Administered by: ??      Purchased by: Unknown
Symptoms: CONVULS, SOMNOLENCE, STUPOR, PALPITAT, SKIN DISCOLOR

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 6     Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: EEG - abnormal, MRI - neg, Viral antigens - neg, CSF results - unk, Septic work up - neg, Herpes test-pending
CDC 'Split Type':

Write-up: Pt became gray and unresponsive 10 min after starting nap.911 called, pt was staring straight ahead, tonic, stiff. Ativan was administered with good response. HR 150, B/P 80, palpitations, postictal sleepiness, 8-10 seizures.Hospitalized.


Changed on 12/8/2009

VAERS ID: 133476 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:Alabama
Vaccinated:2000-01-19
Onset:2000-01-19
Submitted:2000-01-24
Entered:2000-01-28 2000-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: ACEL-IMUNE DTAP (ACEL-IMUNE) / LEDERLE WYETH PHARMACEUTICALS, INC 467012 / 1 LL / IM
HIBV: HIBTITER HIB (HIBTITER) / LEDERLE(PRAXIS) WYETH PHARMACEUTICALS, INC 570403A / 1 RL / IM
IPV: IPV POLIO VIRUS, INACT. (NO BRAND NAME) / MERIEUX INST PASTEUR MERIEUX INST. P0998 / 1 LL / SC

Administered by: (blank) Unknown      Purchased by: Unknown
Symptoms: Convulsion, Electroencephalogram abnormal, Nuclear magnetic resonance imaging normal, Palpitations, Skin discolouration, Somnolence, Staring, Unresponsive to stimuli, Postictal state, Tonic clonic movements, Musculoskeletal stiffness, Laboratory test normal, CSF test, Viral test negative, Herpes simplex serology negative, CONVULS, SOMNOLENCE, STUPOR, PALPITAT, SKIN DISCOLOR

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 6     Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: EEG - abnormal, MRI - neg, Viral antigens - neg, CSF results - unk, Septic work up - neg, Herpes test-pending
CDC 'Split Type':

Write-up: Pt became gray and unresponsive 10 min after starting nap.911 called, pt was staring straight ahead, tonic, stiff. Ativan was administered with good response. HR 150, B/P 80, palpitations, postictal sleepiness, 8-10 seizures.Hospitalized. Follow-up: 2/15/00 consent form returned by parent - Mailed with letter to hospital.


Changed on 8/31/2010

VAERS ID: 133476 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:Alabama
Vaccinated:2000-01-19
Onset:2000-01-19
Submitted:2000-01-24
Entered:2000-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH 467012 / 1 LL / IM
HIBV: HIB (HIBTITER) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH 570403A / 1 RL / IM
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. P0998 / 1 LL / SC

Administered by: Unknown      Purchased by: Unknown
Symptoms: Convulsion, Electroencephalogram abnormal, Nuclear magnetic resonance imaging normal, Palpitations, Skin discolouration, Somnolence, Staring, Unresponsive to stimuli, Postictal state, Tonic clonic movements, Musculoskeletal stiffness, Laboratory test normal, CSF test, Viral test negative, Herpes simplex serology negative

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 6     Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: EEG - abnormal, MRI - neg, Viral antigens - neg, CSF results - unk, Septic work up - neg, Herpes test-pending
CDC 'Split Type':

Write-up: Pt became gray and unresponsive 10 min after starting nap.911 called, pt was staring straight ahead, tonic, stiff. Ativan was administered with good response. HR 150, B/P 80, palpitations, postictal sleepiness, 8-10 seizures.Hospitalized. Follow-up: 2/15/00 consent form returned by parent - Mailed with letter to hospital.


Changed on 6/14/2014

VAERS ID: 133476 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:Alabama
Vaccinated:2000-01-19
Onset:2000-01-19
Submitted:2000-01-24
Entered:2000-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 467012 / 1 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 570403A / 1 RL / IM
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. P0998 / 1 LL / SC

Administered by: Unknown      Purchased by: Unknown
Symptoms: Convulsion, Electroencephalogram abnormal, Nuclear magnetic resonance imaging normal, Palpitations, Skin discolouration, Somnolence, Staring, Unresponsive to stimuli, Postictal state, Tonic clonic movements, Musculoskeletal stiffness, Laboratory test normal, CSF test, Viral test negative, Herpes simplex serology negative

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 6     Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: EEG - abnormal, MRI - neg, Viral antigens - neg, CSF results - unk, Septic work up - neg, Herpes test-pending
CDC 'Split Type':

Write-up: Pt became gray and unresponsive 10 min after starting nap.911 called, pt was staring straight ahead, tonic, stiff. Ativan was administered with good response. HR 150, B/P 80, palpitations, postictal sleepiness, 8-10 seizures.Hospitalized. Follow-up: 2/15/00 consent form returned by parent - Mailed with letter to hospital.


Changed on 2/14/2017

VAERS ID: 133476 Before After
VAERS Form:
Age:0.3 0.34
Sex:Male
Location:Alabama
Vaccinated:2000-01-19
Onset:2000-01-19
Submitted:2000-01-24
Entered:2000-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 467012 / 1 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 570403A / 1 RL / IM
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. P0998 / 1 LL / SC

Administered by: Unknown      Purchased by: Unknown
Symptoms: Convulsion, Electroencephalogram abnormal, Nuclear magnetic resonance imaging normal, Palpitations, Skin discolouration, Somnolence, Staring, Unresponsive to stimuli, Postictal state, Tonic clonic movements, Musculoskeletal stiffness, Laboratory test normal, CSF test, Viral test negative, Herpes simplex serology negative

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 6     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: EEG - abnormal, MRI - neg, Viral antigens - neg, CSF results - unk, Septic work up - neg, Herpes test-pending
CDC 'Split Type':

Write-up: Pt became gray and unresponsive 10 min after starting nap.911 called, pt was staring straight ahead, tonic, stiff. Ativan was administered with good response. HR 150, B/P 80, palpitations, postictal sleepiness, 8-10 seizures.Hospitalized. Follow-up: 2/15/00 consent form returned by parent - Mailed with letter to hospital.


Changed on 5/14/2017

VAERS ID: 133476 Before After
VAERS Form:
Age:0.34
Sex:Male
Location:Alabama
Vaccinated:2000-01-19
Onset:2000-01-19
Submitted:2000-01-24
Entered:2000-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 467012 / 1 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 570403A / 1 RL / IM
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. P0998 / 1 LL / SC

Administered by: Unknown      Purchased by: Unknown
Symptoms: Convulsion, Electroencephalogram abnormal, Nuclear magnetic resonance imaging normal, Palpitations, Skin discolouration, Somnolence, Staring, Unresponsive to stimuli, Postictal state, Tonic clonic movements, Musculoskeletal stiffness, Laboratory test normal, CSF test, Viral test negative, Herpes simplex serology negative

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 6     Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: EEG - abnormal, MRI - neg, Viral antigens - neg, CSF results - unk, Septic work up - neg, Herpes test-pending
CDC 'Split Type':

Write-up: Pt became gray and unresponsive 10 min after starting nap.911 called, pt was staring straight ahead, tonic, stiff. Ativan was administered with good response. HR 150, B/P 80, palpitations, postictal sleepiness, 8-10 seizures.Hospitalized. Follow-up: 2/15/00 consent form returned by parent - Mailed with letter to hospital.


Changed on 9/14/2017

VAERS ID: 133476 Before After
VAERS Form:(blank) 1
Age:0.34
Sex:Male
Location:Alabama
Vaccinated:2000-01-19
Onset:2000-01-19
Submitted:2000-01-24
Entered:2000-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 467012 / 1 2 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 570403A / 1 2 RL / IM
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. P0998 / 1 2 LL / SC

Administered by: Unknown      Purchased by: Unknown
Symptoms: Convulsion, Electroencephalogram abnormal, Nuclear magnetic resonance imaging normal, Palpitations, Skin discolouration, Somnolence, Staring, Unresponsive to stimuli, Postictal state, Tonic clonic movements, Musculoskeletal stiffness, Laboratory test normal, CSF test, Viral test negative, Herpes simplex serology negative

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 6     Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: EEG - abnormal, MRI - neg, Viral antigens - neg, CSF results - unk, Septic work up - neg, Herpes test-pending
CDC 'Split Type':

Write-up: Pt became gray and unresponsive 10 min after starting nap.911 called, pt was staring straight ahead, tonic, stiff. Ativan was administered with good response. HR 150, B/P 80, palpitations, postictal sleepiness, 8-10 seizures.Hospitalized. Follow-up: 2/15/00 consent form returned by parent - Mailed with letter to hospital.


Changed on 2/14/2018

VAERS ID: 133476 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:Alabama
Vaccinated:2000-01-19
Onset:2000-01-19
Submitted:2000-01-24
Entered:2000-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 467012 / 2 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 570403A / 2 RL / IM
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. P0998 / 2 LL / SC

Administered by: Unknown      Purchased by: Unknown
Symptoms: Convulsion, Electroencephalogram abnormal, Nuclear magnetic resonance imaging normal, Palpitations, Skin discolouration, Somnolence, Staring, Unresponsive to stimuli, Postictal state, Tonic clonic movements, Musculoskeletal stiffness, Laboratory test normal, CSF test, Viral test negative, Herpes simplex serology negative

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 6     Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: EEG - abnormal, MRI - neg, Viral antigens - neg, CSF results - unk, Septic work up - neg, Herpes test-pending
CDC 'Split Type':

Write-up: Pt became gray and unresponsive 10 min after starting nap.911 called, pt was staring straight ahead, tonic, stiff. Ativan was administered with good response. HR 150, B/P 80, palpitations, postictal sleepiness, 8-10 seizures.Hospitalized. Follow-up: 2/15/00 consent form returned by parent - Mailed with letter to hospital.


Changed on 6/14/2018

VAERS ID: 133476 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:Alabama
Vaccinated:2000-01-19
Onset:2000-01-19
Submitted:2000-01-24
Entered:2000-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 467012 / 2 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 570403A / 2 RL / IM
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. P0998 / 2 LL / SC

Administered by: Unknown      Purchased by: Unknown
Symptoms: Convulsion, Electroencephalogram abnormal, Nuclear magnetic resonance imaging normal, Palpitations, Skin discolouration, Somnolence, Staring, Unresponsive to stimuli, Postictal state, Tonic clonic movements, Musculoskeletal stiffness, Laboratory test normal, CSF test, Viral test negative, Herpes simplex serology negative

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 6     Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: EEG - abnormal, MRI - neg, Viral antigens - neg, CSF results - unk, Septic work up - neg, Herpes test-pending
CDC 'Split Type':

Write-up: Pt became gray and unresponsive 10 min after starting nap.911 called, pt was staring straight ahead, tonic, stiff. Ativan was administered with good response. HR 150, B/P 80, palpitations, postictal sleepiness, 8-10 seizures.Hospitalized. Follow-up: 2/15/00 consent form returned by parent - Mailed with letter to hospital.


Changed on 8/14/2018

VAERS ID: 133476 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:Alabama
Vaccinated:2000-01-19
Onset:2000-01-19
Submitted:2000-01-24
Entered:2000-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 467012 / 2 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 570403A / 2 RL / IM
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. P0998 / 2 LL / SC

Administered by: Unknown      Purchased by: Unknown
Symptoms: Convulsion, Electroencephalogram abnormal, Nuclear magnetic resonance imaging normal, Palpitations, Skin discolouration, Somnolence, Staring, Unresponsive to stimuli, Postictal state, Tonic clonic movements, Musculoskeletal stiffness, Laboratory test normal, CSF test, Viral test negative, Herpes simplex serology negative

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 6     Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: EEG - abnormal, MRI - neg, Viral antigens - neg, CSF results - unk, Septic work up - neg, Herpes test-pending
CDC 'Split Type':

Write-up: Pt became gray and unresponsive 10 min after starting nap.911 called, pt was staring straight ahead, tonic, stiff. Ativan was administered with good response. HR 150, B/P 80, palpitations, postictal sleepiness, 8-10 seizures.Hospitalized. Follow-up: 2/15/00 consent form returned by parent - Mailed with letter to hospital.


Changed on 9/14/2018

VAERS ID: 133476 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:Alabama
Vaccinated:2000-01-19
Onset:2000-01-19
Submitted:2000-01-24
Entered:2000-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 467012 / 2 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 570403A / 2 RL / IM
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. P0998 / 2 LL / SC

Administered by: Unknown      Purchased by: Unknown
Symptoms: Convulsion, Electroencephalogram abnormal, Nuclear magnetic resonance imaging normal, Palpitations, Skin discolouration, Somnolence, Staring, Unresponsive to stimuli, Postictal state, Tonic clonic movements, Musculoskeletal stiffness, Laboratory test normal, CSF test, Viral test negative, Herpes simplex serology negative

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 6     Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: EEG - abnormal, MRI - neg, Viral antigens - neg, CSF results - unk, Septic work up - neg, Herpes test-pending
CDC 'Split Type':

Write-up: Pt became gray and unresponsive 10 min after starting nap.911 called, pt was staring straight ahead, tonic, stiff. Ativan was administered with good response. HR 150, B/P 80, palpitations, postictal sleepiness, 8-10 seizures.Hospitalized. Follow-up: 2/15/00 consent form returned by parent - Mailed with letter to hospital.


Changed on 10/14/2018

VAERS ID: 133476 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:Alabama
Vaccinated:2000-01-19
Onset:2000-01-19
Submitted:2000-01-24
Entered:2000-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 467012 / 2 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 570403A / 2 RL / IM
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. P0998 / 2 LL / SC

Administered by: Unknown      Purchased by: Unknown
Symptoms: Convulsion, Electroencephalogram abnormal, Nuclear magnetic resonance imaging normal, Palpitations, Skin discolouration, Somnolence, Staring, Unresponsive to stimuli, Postictal state, Tonic clonic movements, Musculoskeletal stiffness, Laboratory test normal, CSF test, Viral test negative, Herpes simplex serology negative

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 6     Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: EEG - abnormal, MRI - neg, Viral antigens - neg, CSF results - unk, Septic work up - neg, Herpes test-pending
CDC 'Split Type':

Write-up: Pt became gray and unresponsive 10 min after starting nap.911 called, pt was staring straight ahead, tonic, stiff. Ativan was administered with good response. HR 150, B/P 80, palpitations, postictal sleepiness, 8-10 seizures.Hospitalized. Follow-up: 2/15/00 consent form returned by parent - Mailed with letter to hospital.


Changed on 12/24/2020

VAERS ID: 133476 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:Alabama
Vaccinated:2000-01-19
Onset:2000-01-19
Submitted:2000-01-24
Entered:2000-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 467012 / 2 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 570403A / 2 RL / IM
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. P0998 / 2 LL / SC

Administered by: Unknown      Purchased by: Unknown
Symptoms: Convulsion, Electroencephalogram abnormal, Nuclear magnetic resonance imaging normal, Palpitations, Skin discolouration, Somnolence, Staring, Unresponsive to stimuli, Postictal state, Tonic clonic movements, Musculoskeletal stiffness, Laboratory test normal, CSF test, Viral test negative, Herpes simplex serology negative

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 6     Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: EEG - abnormal, MRI - neg, Viral antigens - neg, CSF results - unk, Septic work up - neg, Herpes test-pending
CDC 'Split Type':

Write-up: Pt became gray and unresponsive 10 min after starting nap.911 called, pt was staring straight ahead, tonic, stiff. Ativan was administered with good response. HR 150, B/P 80, palpitations, postictal sleepiness, 8-10 seizures.Hospitalized. Follow-up: 2/15/00 consent form returned by parent - Mailed with letter to hospital.


Changed on 12/30/2020

VAERS ID: 133476 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:Alabama
Vaccinated:2000-01-19
Onset:2000-01-19
Submitted:2000-01-24
Entered:2000-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 467012 / 2 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 570403A / 2 RL / IM
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. P0998 / 2 LL / SC

Administered by: Unknown      Purchased by: Unknown
Symptoms: Convulsion, Electroencephalogram abnormal, Nuclear magnetic resonance imaging normal, Palpitations, Skin discolouration, Somnolence, Staring, Unresponsive to stimuli, Postictal state, Tonic clonic movements, Musculoskeletal stiffness, Laboratory test normal, CSF test, Viral test negative, Herpes simplex serology negative

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 6     Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: EEG - abnormal, MRI - neg, Viral antigens - neg, CSF results - unk, Septic work up - neg, Herpes test-pending
CDC 'Split Type':

Write-up: Pt became gray and unresponsive 10 min after starting nap.911 called, pt was staring straight ahead, tonic, stiff. Ativan was administered with good response. HR 150, B/P 80, palpitations, postictal sleepiness, 8-10 seizures.Hospitalized. Follow-up: 2/15/00 consent form returned by parent - Mailed with letter to hospital.

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