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This is VAERS ID 207834

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

Case Details

VAERS ID: 207834 (history)  
Form: Version .0  
Age: 18.0  
Sex: Male  
Location: California  
Vaccinated:2002-11-14
Onset:0000-00-00
Submitted: 2003-08-11
Entered: 2003-08-14
   Days after submission:3
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUZONE) / AVENTIS PASTEUR - / - - / -
HEP: HEP B (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - - / -
HEPA: HEP A (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - - / -
MEN: MENINGOCOCCAL (MENOMUNE) / AVENTIS PASTEUR UB245AA / - - / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. - / - - / -
PPV: PNEUMO (PNEUMOVAX) / MERCK & CO. INC. - / - - / -

Administered by: Military       Purchased by: Unknown
Symptoms: Bacterial infection, Cough, Drug ineffective, Dyspnoea, Laboratory test abnormal, Pharyngitis, Rash maculo-papular, Sepsis, Shock
SMQs:, Anaphylactic reaction (narrow), Agranulocytosis (broad), Lack of efficacy/effect (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Hypovolaemic shock conditions (narrow), Toxic-septic shock conditions (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypoglycaemic and neurogenic shock conditions (narrow), Oropharyngeal infections (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2002-12-15
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: PPD
Current Illness:
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Diagnostic Laboratory: PCR was positive for Neisseria Meningococcal infection serogroup C.
CDC Split Type: 200301574

Write-up: From initial information received on 8/7/03 from a medical professional, regarding an adverse event occurring in the US, it was reported that an 18year old male patient received MENOMUNE, lot number UB245AA, FLUZONE (lot number not reported), TUBERSOL (lot number not reported), HEPATITIS A VACCINE (lot number and manufacturer not reported, HEPATITIS B VACCINE (lot number and manufacturer not reported), MMR (lot number not reported), and PNEUMOVAX (lot number not reported) administered on 11/14/02. All vaccines were administered on the same date. The patient died on 12/15/02. The CDC investigation confirmed that the patient was positive for serogroup C, Meningococcal infection. The onset date of signs and symptoms were not reported. An autopsy was performed, however, results were not available at the time of this report. Follow-up information: Information has been received from a health professional concerning an 18 year old male patient who was healthy with no adverse entry who on 11/14/2002 was vaccinated with a dose of MMRII (Lot # not reported). Concomitant therapy on 11/14/2002 included a dose of hepatitis A vaccine (inactive) (manufacturer unknown) (Lot # not reported), a dose of hepatitis B virus vaccine rHBsAg (yeast) (manufacturer unknown) (Lot # not reported), a dose of pneumococcal vaccine 23 polyvalent (MSD) (Lot # not reported), a dose of tuberculin in purified protein derivative (TUBERSOL) (Lot # not reported), a dose of influenza virus vaccine (FLUZONE) (Lot # not reported) and a dose of meningococcal polysaccharide vaccine (MENOMUME-A/C/Y/W-135) (Lot # UB245AA). Subsequently the patient died on 12/15/2002. It was confirmed that the patient was positive for serogroup C Meningococcal infection. The onset date of signs and symptoms were not reported. An autopsy was performed; however, the results were not available at the time of the report. From additional information received on 08/12/2003 from a pathology department, it was reported that the patient presented with an acute onset of a rash on


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