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This is VAERS ID 189239

Case Details

VAERS ID: 189239 (history)  
Form: Version 1.0  
Age: 17.0  
Sex: Female  
Location: California  
Vaccinated:2001-01-17
Onset:2002-03-07
   Days after vaccination:414
Submitted: 2002-08-21
   Days after onset:166
Entered: 2002-08-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MEN: MENINGOCOCCAL (NO BRAND NAME) / UNKNOWN MANUFACTURER NOT REPORTED / 1 - / -

Administered by: Public       Purchased by: Unknown
Symptoms: Myocarditis
SMQs:, Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2002-03-15
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Ortho-TriCyclen
Current Illness: none
Preexisting Conditions: Mitral Valve Prolapse
Allergies:
Diagnostic Lab Data: no etiology discovered
CDC Split Type:

Write-up: myocarditis


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