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This is VAERS ID 29967

Case Details

VAERS ID: 29967 (history)  
Form: Version 1.0  
Age: 0.3  
Sex: Male  
Location: Florida  
Vaccinated:1991-03-21
Onset:1991-03-22
   Days after vaccination:1
Submitted: 1991-03-22
   Days after onset:0
Entered: 1991-04-19
   Days after submission:27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 291927 / UNK RL / -
HIBV: HIB (HIBTITER) / PFIZER/WYETH M160FH / UNK LL / -
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 291946 / UNK MO / PO

Administered by: Public       Purchased by: Public
Symptoms: Asthenia, Congenital arterial malformation, Face oedema, Heart disease congenital
SMQs:, Anaphylactic reaction (broad), Angioedema (narrow), Congenital, familial and genetic disorders (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1991-03-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: Baby Aspirin 1 daily
Current Illness: Congenital Heart Disease
Preexisting Conditions: Hypoplastic lt heart synd
Allergies:
Diagnostic Lab Data:
CDC Split Type: FL91013

Write-up: TC fr mom infant has swollen eyes; Starts to suck from bottle & quits, "acts like he is worn out"; Referred for eval; no fever;


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