| VAERS ID: |
250504 (history) |
| Form: |
Version 1.0 |
| Age: |
1.02 |
| Sex: |
Male |
| Location: |
Virginia |
| Vaccinated: | 2005-10-25 |
| Onset: | 2005-10-30 |
| Days after vaccination: | 5 |
| Submitted: |
0000-00-00 |
| Entered: |
2006-01-18 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR |
U1762AA / UNK |
- / - |
| MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. |
0935P / UNK |
LL / - |
| VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. |
0195P / UNK |
RL / - |
Administered by: Private Purchased by: Other
Symptoms: Irritability,
Pyrexia,
Sudden infant death syndrome
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Neonatal disorders (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2005-10-30
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: Child reportedly fussy, irritable and with mild fever during interval between vaccines and death. 2/27/06 Received autopsy report which reveals patient''s COD was Sudden Unexpected Death in Childhood/ss No new information found in medical records from PCP. |
