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This is VAERS ID 217129

(NOTE: This result is from the 12/30/2004 version of the VAERS database)

Case Details

VAERS ID: 217129 (history)  
Form: Version .0  
Age: 1.7  
Sex: Male  
Location: California  
Vaccinated:2004-02-26
Onset:2004-02-26
   Days after vaccination:0
Submitted: 2004-03-02
   Days after onset:5
Entered: 2004-03-03
   Days after submission:1
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP HEPB IPV (PEDIARIX) / GLAXOSMITHKLINE 21893B9 / 1 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0915N / 1 RL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0178N / 0 RL / SC
PNC: PNEUMO, 7-VALENT (PREVNAR) / LEDERLE LABORATO 493505 / 1 RL / IM
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 0196N / 0 LL / IM

Administered by: Private       Purchased by: Unknown
Symptoms: AGITATION, ANOMALY HEART, FEVER, HEM ADREN, INFECT BACT
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2004-02-26
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Aspirin 1/2 tab per day (baby Aspirin)
Current Illness: NONE
Preexisting Conditions: Cardiac heterotaxy; Dextrocardia; Complete AV Septal defect; Pulmonary Atresia
Allergies:
Diagnostic Lab Data: blood culture (+) for streptococcus pneumoniae;
CDC Split Type:

Write-up: According to family, 3 hours after immunizations given, patient had vomiting and temperature of 103. Arrived in ER 2/26/04 at 21:15; temp was 106 rectally. C/C to ER; was crying, fever, vomiting. Died 2/26/04 at 23:58.


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