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This is VAERS ID 30808

Case Details

VAERS ID: 30808 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: California  
Vaccinated:1991-05-08
Onset:1991-05-10
   Days after vaccination:2
Submitted: 1991-05-17
   Days after onset:7
Entered: 1991-05-23
   Days after submission:6
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 1E21008 / 1 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M1204A / 1 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 297957 / 1 MO / PO

Administered by: Private       Purchased by: Private
Symptoms: Agitation, Diarrhoea, Polyuria
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Dementia (broad), Pseudomembranous colitis (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hostility/aggression (broad), Noninfectious diarrhoea (narrow), Tubulointerstitial diseases (broad), Hypoglycaemia (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1991-05-10
   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: NONE
Current Illness: NONE
Preexisting Conditions: Intolerant to CM & Soy formulas x/soyalac
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt rec''d initial DPT/OPV/HIB developed fretful later the same day, rec''d APAP; Stools seemed loose; child voided more than usual; But looked OK next day, died unexpectedly in sleep;


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