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This is VAERS ID 250332

Case Details

VAERS ID: 250332 (history)  
Form: Version 1.0  
Age: 20.0  
Sex: Male  
Location: Unknown  
Vaccinated:2004-11-23
Onset:2004-11-30
   Days after vaccination:7
Submitted: 2006-01-13
   Days after onset:409
Entered: 2006-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U1501AA / 1 UN / IM
HEPA: HEP A (NO BRAND NAME) / UNKNOWN MANUFACTURER AHABA015AA / 2 UN / UN
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0706 / 1 UN / SC
MEN: MENINGOCOCCAL (NO BRAND NAME) / UNKNOWN MANUFACTURER UE122AA / 1 UN / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0781P / 1 UN / SC
TD: TD ADSORBED (NO BRAND NAME) / SANOFI PASTEUR 01282AA / 1 UN / IM

Administered by: Military       Purchased by: Military
Symptoms: Asthma, Chest pain, Cough, Loss of consciousness, Myocarditis, Nasal congestion, Oedema
SMQs:, Torsade de pointes/QT prolongation (broad), Cardiac failure (broad), Anaphylactic reaction (narrow), Angioedema (broad), Asthma/bronchospasm (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2005-02-17
   Days after onset: 79
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Asthma age 5
Allergies:
Diagnostic Lab Data: 18 Feb 05: Cardiac-normal distribution of small patent coronary arteries. The valves appear normal. The myocardium does not show any acute changes. The left ventricle measures 1.4 cm in thickness. The septum measures 1.4 cm in thickness. The aorta has youthful intima. Resp-prominent congestion and mild edema without any discrete lesion. The airways patent. The vasculature free of thromboemboli. Microscopic Exam: Heart the mural sections show rare perivascular mononuclear cells some with plasmacytoid features. The AV node section shows extensive infiltration with mononuclear cells many of which are necrotic. Lung there is edema and congestion with focal mild interstitial chronic inflammation and proliferation of pigmented alveolar macrophages. Brain and live - unremarkable. Kidney a rare Bowman capsule sclerosis is seen in the cortex. Pathologic diagnosis: Chronic myocarditis involving AV node. No lethal injuries.
CDC Split Type:

Write-up: The Department of Health informed the HC in May 05 of the death of a medically discharged patient. The patient enlisted in Nov 04, medically discharged in Jan 05, and died on Feb 17th. The following HPI is an account of the events prior to his death as recalled by his mother during an interview in May 05. The service member a 20 year old male, who received his enlistment vaccines on 23 Nov 04. While speaking with his mom on 30 Nov he mentioned that he had a cough, and some chest pain. She state that she encourage him to seek medical attention. She state that a couple of days later, while he was running he ''passed out'' and when he went to the doctor he was told it was asthma. Mom reported that while he was at home during Christmas, he reported to his family that he was experiencing some chest pain, and did have bumps on his face that cleared in Jan. Mom was unaware of which vaccines her son received but did remember that her son said that the needle was "funny." Mom does not recall if he had a scar on his arm. She state that he was discharged for stress related issues and complaints of chest pain. Mom is unaware of any other details regarding her son''s illness during that time only that the chest pain persisted. When questioned about his past history of asthma, she mentioned that he had it a little in childhood but has not been bothered by it since that time. She did mention that her son felt that his pain was not related to asthma. Mom was also questioned about the waiver for a medical exam upon discharge. She state that he was told that if he requested a workup, it would delay his release and that they may not even discharge him. He received his enlistment vaccines of Hep A-Hep B, Influenza, Meningococcal, MRR, Polio, and Td on 23 Nov 04 and he received his second Hep A-Hep B on 5 Jan 05. Chest pain start 11/30/2004, dyspnea (shortness of breath) start 11/30/2004. 4/3/06 Received Autopsy Report which revealed COD as chronic myocarditis.


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