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This is VAERS ID 257684

(NOTE: This result is from the 9/14/2018 version of the VAERS database)

Case Details

VAERS ID: 257684 (history)  
Form: Version 1.0  
Age: 1.33  
Sex: Female  
Location: Arkansas  
Vaccinated:2006-05-31
Onset:2006-06-01
   Days after vaccination:1
Submitted: 2006-06-02
   Days after onset:1
Entered: 2006-06-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / SANOFI PASTEUR U1774CA / 2 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UE795AA / 3 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR YO991 / 2 LL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0092F / 1 LA / SC
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08653R / 3 RL / IM
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 1022R / 1 LL / SC

Administered by: Unknown       Purchased by: Unknown
Symptoms: Apnoea, Cardio-respiratory arrest, Circulatory collapse, Dehydration, Hypoxia, Neurodevelopmental disorder, Pneumonia, Pyrexia, Respiratory distress
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Asthma/bronchospasm (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (narrow), Hypovolaemic shock conditions (narrow), Toxic-septic shock conditions (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypoglycaemic and neurogenic shock conditions (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Eosinophilic pneumonia (broad), Hypersensitivity (narrow), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2006-06-02
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Prevacid, Tabs 15 mg Solutab PO Oxygen at home device Albuterol MDI, Inhaler, 90 mcg, Atrovent nasal Spray (0.03%) Metoclopramide, Syrup 5mg/5ml .8ml Nystatin Powder Was given Augmentin ES-600 susp, for otitis media the day she was in offic
Current Illness: Otitis Media Bi latteral
Preexisting Conditions: Gerd, Scoliosis- Idiopathic, Tracheomalacia,Wheezing, Developemental Delay, Speech Delay, Otitis Media-Chronic Supporative Bilateral
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Received immunizations in this office on 5/31/06. She was noted to have an otitis media withoutfever. Mother called the office on 6/1/06 and talked to the nurse because she was running a fever and not acting quite right. She was given standard instruction for post immunization. During the night she became febrile and started having respiratory difficulties with her pulse ox dropping into the 80''s. Mother drove her to the emergency room. In route the child became apneic. By the time she arrived she was asytolic. Rescussitation was unsuccessful. She had a temperature of 107 when she arrived in the ER.This patient had fever and cardiovascular colapse within 48 hours of immunization. I feel this was a major immunization reaction. 7/18/06 Received medical records from ER which reveal patient developed respiratory distress & failure. PMH: tracheomalacia, developmental delay, chronic respiratory deficitis & congenital heart defects. Had trach & PEG in place & was on home O2. Developed decreased LOC prior to hospitalization with cyanosis despite O2. Found to be febrile at 107, apneic & asystolic in ER & resuscitation was unsuccessful. 7/31/06 Received medical records from PCP which did not add new info. 8/9/06 Received Death Certificate which stated COD as pneumonia with dehydration with tracheomalacia as underlying cause./ss


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