| VAERS ID: |
151621 (history) |
| Form: |
Version .0 |
| Age: |
0.2 |
| Sex: |
Male |
| Location: |
Connecticut |
| Vaccinated: | 2000-05-02 |
| Onset: | 2000-05-03 |
| Days after vaccination: | 1 |
| Submitted: |
2000-05-03 |
| Days after onset: | 0 |
| Entered: |
2000-05-05 |
| Days after submission: | 2 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES |
U0045BA / 0 |
RL / IM |
| HIBV: HIB (HIBTITER) / PFIZER/WYETH |
56092A / 0 |
RL / IM |
| IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. |
R0100 / 0 |
LL / SC |
Administered by: Private Purchased by: Public
Symptoms: Apnoea,
Cardiac arrest,
Sudden infant death syndrome
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Cardiomyopathy (broad), Neonatal disorders (narrow), Respiratory failure (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2000-05-03
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: Previous rule/out Sepsis with/out dx viral
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: Found apneic and asystolic, tied up in blankets 24 hours after vax. Autopsy shows final cause of death as sudden infant death syndrome. A follow up report received 6/12/2000 clarifies that pt was found "tangled up in his blankets" rather than "tied up in blankets". |
