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From the 5/7/2021 release of VAERS data:

This is VAERS ID 133531



Case Details

VAERS ID: 133531 (history)  
Form: Version 1.0  
Age: 0.1  
Sex: Female  
Location: New York  
Vaccinated:2000-01-19
Onset:2000-01-19
   Days after vaccination:0
Submitted: 2000-01-21
   Days after onset:2
Entered: 2000-01-28
   Days after submission:7
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES U0039CA / 1 RL / IM
HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC. 12453 / 1 RL / SC
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. R0395 / 1 RL / SC

Administered by: Private       Purchased by: Private
Symptoms: Hypertonia, Salivary hypersecretion, Skin discolouration, Stupor
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Parkinson-like events (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), Hypokalaemia (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Tylenol
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: To be performed, CBC, BC, U, C, LP, labs were nml.
CDC Split Type:

Write-up: 45 min post vax, pt develops foaming mouth, stiffening, ashen color, not responsive for couple of seconds. Pt taken to ER. Admitted for full sepsis work up and seizure work up. Tx w/ amipicillin.


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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=133531


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