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This is VAERS ID 257684

History of Changes from the VAERS Wayback Machine

First Appeared on 12/30/2006

VAERS ID: 257684
VAERS Form:
Age:1.3
Sex:Female
Location:Arkansas
Vaccinated:2006-05-31
Onset:2006-06-01
Submitted:2006-06-02
Entered:2006-06-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / AVENTIS PASTEUR, INC. U1774CA / 1 RL / IM
HIBV: HIB (ACTHIB) / AVENTIS PASTEUR, INC. UE795AA / 2 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / AVENTIS PASTEUR, INC. YO991 / 1 LL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0092F / 0 LA / SC
PNC: PNEUMO, 7-VALENT (PREVNAR) / LEDERLE LABORATORIES B08653R / 2 RL / IM
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 1022R / 0 LL / SC

Administered by: Unknown      Purchased by: Unknown
Symptoms: Apnoea, Cardio-respiratory arrest, Circulatory collapse, Dehydration, Hypoxia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2006-06-02
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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
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 asy


Changed on 12/8/2009

VAERS ID: 257684 Before After
VAERS Form:
Age:1.3
Sex:Female
Location:Arkansas
Vaccinated:2006-05-31
Onset:2006-06-01
Submitted:2006-06-02
Entered:2006-06-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / AVENTIS PASTEUR, INC. AVENTIS PASTEUR U1774CA / 1 RL / IM
HIBV: HIB (ACTHIB) / AVENTIS PASTEUR, INC. AVENTIS PASTEUR UE795AA / 2 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / AVENTIS PASTEUR, INC. AVENTIS PASTEUR YO991 / 1 LL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0092F / 0 LA / SC
PNC: PNEUMO, 7-VALENT (PREVNAR) PNEUMO (PREVNAR) / LEDERLE LABORATORIES B08653R / 2 RL / IM
VARCEL: VARICELLA (VARIVAX) VARICELLA (VARIVAX) / MERCK & CO. INC. 1022R / 0 LL / SC

Administered by: Unknown      Purchased by: Unknown
Symptoms: Apnoea, Cardio-respiratory arrest, Circulatory collapse, Dehydration, Hypoxia, Pneumonia, Pyrexia, Respiratory distress, Neurodevelopmental disorder

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2006-06-02
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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
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 instruction for post immunization. During the night she became febrile and started having respiratory difficulties with her pulse ox dropping into the 80''''s. 80''s. Mother drove her to the emergency room. In route the child became apneic. By the time she arrived she was asy 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


Changed on 3/2/2010

VAERS ID: 257684 Before After
VAERS Form:
Age:1.3
Sex:Female
Location:Arkansas
Vaccinated:2006-05-31
Onset:2006-06-01
Submitted:2006-06-02
Entered:2006-06-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / AVENTIS PASTEUR U1774CA / 1 RL / IM
HIBV: HIB (ACTHIB) / AVENTIS PASTEUR UE795AA / 2 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / AVENTIS PASTEUR YO991 / 1 LL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0092F / 0 LA / SC
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / LEDERLE LABORATORIES B08653R / 2 RL / IM
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 1022R / 0 LL / SC

Administered by: Unknown      Purchased by: Unknown
Symptoms: Apnoea, Cardio-respiratory arrest, Circulatory collapse, Dehydration, Hypoxia, Pneumonia, Pyrexia, Respiratory distress, Neurodevelopmental disorder

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2006-06-02
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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
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


Changed on 4/7/2010

VAERS ID: 257684 Before After
VAERS Form:
Age:1.3
Sex:Female
Location:Arkansas
Vaccinated:2006-05-31
Onset:2006-06-01
Submitted:2006-06-02
Entered:2006-06-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / AVENTIS PASTEUR U1774CA / 1 RL / IM
HIBV: HIB (ACTHIB) / AVENTIS PASTEUR UE795AA / 2 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / AVENTIS PASTEUR YO991 / 1 LL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0092F / 0 LA / SC
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / LEDERLE LABORATORIES B08653R / 2 RL / IM
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 1022R / 0 LL / SC

Administered by: Unknown      Purchased by: Unknown
Symptoms: Apnoea, Cardio-respiratory arrest, Circulatory collapse, Dehydration, Hypoxia, Pneumonia, Pyrexia, Respiratory distress, Neurodevelopmental disorder

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2006-06-02
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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
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


Changed on 2/14/2017

VAERS ID: 257684 Before After
VAERS Form:
Age:1.3 1.33
Sex:Female
Location:Arkansas
Vaccinated:2006-05-31
Onset:2006-06-01
Submitted:2006-06-02
Entered:2006-06-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / AVENTIS PASTEUR SANOFI PASTEUR U1774CA / 1 RL / IM
HIBV: HIB (ACTHIB) / AVENTIS PASTEUR SANOFI PASTEUR UE795AA / 2 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / AVENTIS PASTEUR SANOFI PASTEUR YO991 / 1 LL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0092F / 0 LA / SC
PNC: PNEUMO (PREVNAR) / LEDERLE LABORATORIES PFIZER/WYETH B08653R / 2 RL / IM
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 1022R / 0 LL / SC

Administered by: Unknown      Purchased by: Unknown
Symptoms: Apnoea, Cardio-respiratory arrest, Circulatory collapse, Dehydration, Hypoxia, Pneumonia, Pyrexia, Respiratory distress, Neurodevelopmental disorder

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2006-06-02
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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


Changed on 9/14/2017

VAERS ID: 257684 Before After
VAERS Form:(blank) 1
Age:1.33
Sex:Female
Location:Arkansas
Vaccinated:2006-05-31
Onset:2006-06-01
Submitted:2006-06-02
Entered:2006-06-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / SANOFI PASTEUR U1774CA / 1 2 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UE795AA / 2 3 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR YO991 / 1 2 LL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0092F / 0 1 LA / SC
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08653R / 2 3 RL / IM
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 1022R / 0 1 LL / SC

Administered by: Unknown      Purchased by: Unknown
Symptoms: Apnoea, Cardio-respiratory arrest, Circulatory collapse, Dehydration, Hypoxia, Pneumonia, Pyrexia, Respiratory distress, Neurodevelopmental disorder

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2006-06-02
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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


Changed on 2/14/2018

VAERS ID: 257684 Before After
VAERS Form:1
Age:1.33
Sex:Female
Location:Arkansas
Vaccinated:2006-05-31
Onset:2006-06-01
Submitted:2006-06-02
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, Pneumonia, Pyrexia, Respiratory distress, Neurodevelopmental disorder

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2006-06-02
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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


Changed on 6/14/2018

VAERS ID: 257684 Before After
VAERS Form:1
Age:1.33
Sex:Female
Location:Arkansas
Vaccinated:2006-05-31
Onset:2006-06-01
Submitted:2006-06-02
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, Pneumonia, Pyrexia, Respiratory distress, Neurodevelopmental disorder

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2006-06-02
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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


Changed on 8/14/2018

VAERS ID: 257684 Before After
VAERS Form:1
Age:1.33
Sex:Female
Location:Arkansas
Vaccinated:2006-05-31
Onset:2006-06-01
Submitted:2006-06-02
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, Pneumonia, Pyrexia, Respiratory distress, Neurodevelopmental disorder

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2006-06-02
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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


Changed on 9/14/2018

VAERS ID: 257684 Before After
VAERS Form:1
Age:1.33
Sex:Female
Location:Arkansas
Vaccinated:2006-05-31
Onset:2006-06-01
Submitted:2006-06-02
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, Pneumonia, Pyrexia, Respiratory distress, Neurodevelopmental disorder

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2006-06-02
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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


Changed on 10/14/2018

VAERS ID: 257684 Before After
VAERS Form:1
Age:1.33
Sex:Female
Location:Arkansas
Vaccinated:2006-05-31
Onset:2006-06-01
Submitted:2006-06-02
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, Pneumonia, Pyrexia, Respiratory distress, Neurodevelopmental disorder

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2006-06-02
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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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