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From the 6/14/2018 release of VAERS data (an older release, current is 2/18/2021):

This is VAERS ID 277567

Case Details

VAERS ID: 277567 (history)  
Form: Version 1.0  
Age: 0.6  
Sex: Male  
Location: North Carolina  
   Days after vaccination:18
Submitted: 2007-04-27
   Days after onset:12
Entered: 2007-04-30
   Days after submission:3
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: Other
Symptoms: Intussusception, Surgery
SMQs:, Gastrointestinal obstruction (narrow)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Unknown medical records received 5/2/07-PMH RSV. Pneumonia.
Diagnostic Lab Data: Unknown records received 5/2/07-Barium enema
CDC Split Type: WAES0704USA04328

Write-up: Information has been received from a registered nurse concerning a female who was vaccinated PO with a third dose of Rotateq. Subsequently, about a month after vaccination, the patient experienced intussusception. It was noted that the patient had surgery, but no additional information was available. There was no product quality complaint. Intussusception was considered to be immediately life-threatening and disabling and an other important medical event. Additional information has been requested. 05/02/07-records received for DOS 04/15-04/17/07-DC DX:Intussusception. Presented with sudden onset of emesis and bloody stool. Barium enema and attempt to reduce radiologiclly was unsuccessful. Surgery laprascopic reduction and appendectomy.

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