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This is VAERS ID 165922

(NOTE: This result is from the 12/8/2009 version of the VAERS database)

Case Details

VAERS ID: 165922 (history)  
Form: Version .0  
Age: 1.0  
Sex: Male  
Location: Florida  
Vaccinated:2000-12-12
Onset:0000-00-00
Submitted: 2001-02-13
Entered: 2001-02-16
   Days after submission:3
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HIBV: HIB (HIBTITER) / LEDERLE PRAXSIS 581253 / 2 RL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0580K / 0 RL / SC
PNC: PNEUMO (PREVNAR) / LEDERLE LABORATORIES 475382 / 1 LL / IM
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 1249K / 0 LL / SC

Administered by: Private       Purchased by: Public
Symptoms: Cardio-respiratory arrest, Encephalopathy
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 (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2000-12-13
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Flovent, albuterol
Current Illness: Gastroenteritis
Preexisting Conditions: Chronic lung disease; prematurity
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: This infant died of cardiopulmonary arrest of unknown etiology; at this time autopsy is pending. Autopsy stated cause of death as acute encephalopathy. 3


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https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20091208&IDNUMBER=165922


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