VAERS ID: |
213825 (history) |
Form: |
Version 1.0 |
Age: |
1.0 |
Sex: |
Female |
Location: |
Michigan |
Vaccinated: | 2003-05-22 |
Onset: | 2003-06-05 |
Days after vaccination: | 14 |
Submitted: |
2003-12-04 |
Days after onset: | 182 |
Entered: |
2003-12-11 |
Days after submission: | 7 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. |
1012M / 1 |
RL / SC |
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH |
491169 / 3 |
LL / IM |
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. |
0865M / 1 |
LA / SC |
Administered by: Private Purchased by: Public Symptoms: Bacterial infection,
Brain oedema,
Bronchitis,
Pneumonia SMQs:, Hyponatraemia/SIADH (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2003-06-05
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: NONE Allergies: Diagnostic Lab Data: CDC Split Type:
Write-up: Child died suddenly at day care on or about 6/5/03. No other specifics known. Autopsy report report received on 12/16/2003 states COD was bacterial pneumonia, bronchitis, and cerebral edema. |