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This is VAERS ID 30667

Case Details

VAERS ID: 30667 (history)  
Form: Version 1.0  
Age: 0.3  
Sex: Male  
Location: New York  
Vaccinated:1991-05-03
Onset:1991-05-07
   Days after vaccination:4
Submitted: 1991-05-14
   Days after onset:7
Entered: 1991-05-20
   Days after submission:6
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 0C21045 / 2 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M130HA / 2 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 295957 / 2 MO / PO

Administered by: Private       Purchased by: Private
Symptoms: Apnoea, Cardiac arrest, Sudden infant death syndrome
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Cardiomyopathy (broad), Neonatal disorders (narrow), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1991-05-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: none~ ()~~~In patient
Other Medications: pt was finishing course of Ceclor
Current Illness: resolving otitis media
Preexisting Conditions: rt hydrocele
Allergies:
Diagnostic Lab Data: Autopsy done 7May91.Provisional Anatomic Diagnoses:Consistent /w SIDS
CDC Split Type:

Write-up: Pt recvd immun on 3May91,@time of 4mo well baby checkup.Pt was seen in ER on 7May91 @ 630am in cardiac & respiratory arrest as an apparent SIDS death & pronounced dead /p CPR attempts.


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