| VAERS ID: |
217129 (history) |
| Form: |
Version 1.0 |
| 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 |
| DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS |
21893B9 / 2 |
LL / IM |
| HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. |
0915N / 2 |
RL / IM |
| MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. |
0178N / 1 |
RL / SC |
| PNC: PNEUMO (PREVNAR) / PFIZER/WYETH |
493505 / 2 |
RL / IM |
| VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. |
0196N / 1 |
LL / IM |
Administered by: Private Purchased by: Private
Symptoms: Adrenal haemorrhage,
Bacterial infection,
Crying,
Heart disease congenital,
Pyrexia,
Sepsis,
Shock,
Vomiting
SMQs:, Anaphylactic reaction (narrow), Acute pancreatitis (broad), Agranulocytosis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), 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), Congenital, familial and genetic disorders (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Depression (excl suicide and self injury) (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)
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. The hospital discharge summary received on 3/23/04 states meningococcaemia/ sepsis and congenital heart dx. Nurse follow up on 09/21/04 states: "septic shock, adrenal hemorrhage." |
