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This is VAERS ID 34628

Case Details

VAERS ID: 34628 (history)  
Form: Version 1.0  
Age: 0.1  
Sex: Male  
Location: Pennsylvania  
Vaccinated:1991-04-19
Onset:1991-04-20
   Days after vaccination:1
Submitted: 1991-07-15
   Days after onset:86
Entered: 1991-09-10
   Days after submission:57
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 0C21000 / 1 - / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M635FN / 1 - / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 297950 / 1 MO / PO

Administered by: Private       Purchased by: Private
Symptoms: Apnoea, Bradycardia, Cardiac arrest
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), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1991-05-14
   Days after onset: 24
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: Caffeine, Polyvisol
Current Illness: NONE
Preexisting Conditions: prematurity, obstructive apnea
Allergies:
Diagnostic Lab Data: See admission H & P
CDC Split Type:

Write-up: Pt recvd DTP/OPV/HIB evening 19APR91 & returned to office w/profound apnea & bradycardia requiring mechanical ventilation 20APR91 @ 930AM; Pt expired 14MAY91 of cardio-respiratory arrest p/transfer there on 20APR91;


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