| VAERS ID: |
165922 (history) |
| Form: |
Version 1.0 |
| 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) / PFIZER/WYETH |
581253 / 3 |
RL / IM |
| MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. |
0580K / 1 |
RL / SC |
| PNC: PNEUMO (PREVNAR) / PFIZER/WYETH |
475382 / 2 |
LL / IM |
| VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. |
1249K / 1 |
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), Chronic kidney disease (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)
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. |
