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This is VAERS ID 397123

History of Changes from the VAERS Wayback Machine

First Appeared on 9/22/2010

VAERS ID: 397123
VAERS Form:
Age:14.0
Sex:Male
Location:Wisconsin
Vaccinated:2007-07-31
Onset:2010-06-06
Submitted:2010-09-01
Entered:2010-09-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEPA: HEP A (NO BRAND NAME) / UNKNOWN MANUFACTURER AHAVB179AA / 0 RA / UN
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U2388AA / 0 LA / IM

Administered by: Private      Purchased by: Private
Symptoms: Bacteraemia, Cardiac failure, Renal disorder, Shock, Calcium ionised decreased, Culture positive, Neisseria test positive

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-06-06
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Prednisone 60 mg every other day at time of illness (unknown if taking at time of vaccination)
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Neisseria meningitidis serogroup Y isolated from blood, confirmed by culture (collection date: 6/8/2010)
CDC 'Split Type':

Write-up: Primary bacteremia, complications resulted in heart failure. (Note: Patient was on 60 mg prednisone every other day for kidney problems.)


Changed on 1/4/2011

VAERS ID: 397123 Before After
VAERS Form:
Age:14.0
Sex:Male
Location:Wisconsin
Vaccinated:2007-07-31
Onset:2010-06-06
Submitted:2010-09-01
Entered:2010-09-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEPA: HEP A (NO BRAND NAME) / UNKNOWN MANUFACTURER AHAVB179AA / 0 RA / UN
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U2388AA / 0 LA / IM

Administered by: Private      Purchased by: Private
Symptoms: Bacteraemia, Cardiac failure, Renal disorder, Shock, Calcium ionised decreased, Culture positive, Neisseria test positive

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-06-06
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Prednisone 60 mg every other day at time of illness (unknown if taking at time of vaccination)
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Neisseria meningitidis serogroup Y isolated from blood, confirmed by culture (collection date: 6/8/2010)
CDC 'Split Type':

Write-up: Primary bacteremia, complications resulted in heart failure. (Note: Patient was on 60 mg prednisone every other day for kidney problems.)


Changed on 4/13/2011

VAERS ID: 397123 Before After
VAERS Form:
Age:14.0
Sex:Male
Location:Wisconsin
Vaccinated:2007-07-31
Onset:2010-06-06
Submitted:2010-09-01
Entered:2010-09-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEPA: HEP A (NO BRAND NAME) / UNKNOWN MANUFACTURER AHAVB179AA / 0 RA / UN
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U2388AA / 0 LA / IM

Administered by: Private      Purchased by: Private
Symptoms: Acute respiratory distress syndrome, Adrenal disorder, Arthralgia, Aspartate aminotransferase increased, Bacteraemia, Blood albumin decreased, Blood calcium decreased, Blood creatinine increased, Blood culture positive, Blood gases abnormal, Blood potassium decreased, Carbon dioxide decreased, Cardiac failure, Chest X-ray abnormal, Endocarditis, Headache, Heart rate decreased, Hepatic congestion, Intensive care, Jarisch-Herxheimer reaction, Lymphocyte count decreased, Malaise, Multi-organ failure, Pneumonia, Protein total decreased, Pyrexia, Renal disorder, Renal failure acute, Sepsis, Shock, Tachypnoea, Vomiting, Acute endocarditis, Neutrophil percentage increased, Monocyte percentage decreased, Lymphocyte percentage decreased, Calcium ionised decreased, Culture positive, Echocardiogram abnormal, Acute lung injury, Neisseria test positive

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-06-06
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Prednisone 60 mg every other day at time of illness (unknown if taking at time of vaccination)
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Neisseria meningitidis serogroup Y isolated from blood, confirmed by culture (collection date: 6/8/2010)
CDC 'Split Type':

Write-up: Primary bacteremia, complications resulted in heart failure. (Note: Patient was on 60 mg prednisone every other day for kidney problems.)


Changed on 5/13/2011

VAERS ID: 397123 Before After
VAERS Form:
Age:14.0
Sex:Male
Location:Wisconsin
Vaccinated:2007-07-31
Onset:2010-06-06
Submitted:2010-09-01
Entered:2010-09-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEPA: HEP A (NO BRAND NAME) / UNKNOWN MANUFACTURER AHAVB179AA / 0 RA / UN
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U2388AA / 0 LA / IM

Administered by: Private      Purchased by: Private
Symptoms: Acute respiratory distress syndrome, Adrenal disorder, Arthralgia, Aspartate aminotransferase increased, Bacteraemia, Blood albumin decreased, Blood calcium decreased, Blood creatinine increased, Blood culture positive, Blood gases abnormal, Blood potassium decreased, Carbon dioxide decreased, Cardiac failure, Chest X-ray abnormal, Endocarditis, Headache, Heart rate decreased, Hepatic congestion, Intensive care, Jarisch-Herxheimer reaction, Lymphocyte count decreased, Malaise, Multi-organ failure, Pneumonia, Protein total decreased, Pyrexia, Renal disorder, Renal failure acute, Sepsis, Shock, Tachypnoea, Vomiting, Acute endocarditis, Neutrophil percentage increased, Monocyte percentage decreased, Lymphocyte percentage decreased, Calcium ionised decreased, Culture positive, Echocardiogram abnormal, Acute lung injury, Neisseria test positive

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-06-06
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Prednisone 60 mg every other day at time of illness (unknown if taking at time of vaccination)
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Neisseria meningitidis serogroup Y isolated from blood, confirmed by culture (collection date: 6/8/2010)
CDC 'Split Type':

Write-up: Primary bacteremia, complications resulted in heart failure. (Note: Patient was on 60 mg prednisone every other day for kidney problems.)


Changed on 6/14/2014

VAERS ID: 397123 Before After
VAERS Form:
Age:14.0
Sex:Male
Location:Wisconsin
Vaccinated:2007-07-31
Onset:2010-06-06
Submitted:2010-09-01
Entered:2010-09-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEPA: HEP A (NO BRAND NAME) / UNKNOWN MANUFACTURER AHAVB179AA / 0 RA / UN
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U2388AA / 0 LA / IM

Administered by: Private      Purchased by: Private
Symptoms: Bacteraemia, Cardiac failure, Renal disorder, Culture positive, Neisseria test positive

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-06-06
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Prednisone 60 mg every other day at time of illness (unknown if taking at time of vaccination)
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Neisseria meningitidis serogroup Y isolated from blood, confirmed by culture (collection date: 6/8/2010)
CDC 'Split Type':

Write-up: Primary bacteremia, complications resulted in heart failure. (Note: Patient was on 60 mg prednisone every other day for kidney problems.)


Changed on 8/14/2014

VAERS ID: 397123 Before After
VAERS Form:
Age:14.0
Sex:Male
Location:Wisconsin
Vaccinated:2007-07-31
Onset:2010-06-06
Submitted:2010-09-01
Entered:2010-09-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEPA: HEP A (NO BRAND NAME) HEP A (HAVRIX) / UNKNOWN MANUFACTURER GLAXOSMITHKLINE BIOLOGICALS AHAVB179AA / 0 RA / UN
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U2388AA / 0 LA / IM

Administered by: Private      Purchased by: Private
Symptoms: Bacteraemia, Cardiac failure, Renal disorder, Culture positive, Neisseria test positive

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-06-06
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Prednisone 60 mg every other day at time of illness (unknown if taking at time of vaccination)
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Neisseria meningitidis serogroup Y isolated from blood, confirmed by culture (collection date: 6/8/2010)
CDC 'Split Type':

Write-up: Primary bacteremia, complications resulted in heart failure. (Note: Patient was on 60 mg prednisone every other day for kidney problems.)


Changed on 9/14/2017

VAERS ID: 397123 Before After
VAERS Form:(blank) 1
Age:14.0
Sex:Male
Location:Wisconsin
Vaccinated:2007-07-31
Onset:2010-06-06
Submitted:2010-09-01
Entered:2010-09-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS AHAVB179AA / 0 1 RA / UN
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U2388AA / 0 1 LA / IM

Administered by: Private      Purchased by: Private
Symptoms: Bacteraemia, Cardiac failure, Renal disorder, Culture positive, Neisseria test positive

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-06-06
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Prednisone 60 mg every other day at time of illness (unknown if taking at time of vaccination)
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Neisseria meningitidis serogroup Y isolated from blood, confirmed by culture (collection date: 6/8/2010)
CDC 'Split Type':

Write-up: Primary bacteremia, complications resulted in heart failure. (Note: Patient was on 60 mg prednisone every other day for kidney problems.)


Changed on 2/14/2018

VAERS ID: 397123 Before After
VAERS Form:1
Age:14.0
Sex:Male
Location:Wisconsin
Vaccinated:2007-07-31
Onset:2010-06-06
Submitted:2010-09-01
Entered:2010-09-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS AHAVB179AA / 1 RA / UN
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U2388AA / 1 LA / IM

Administered by: Private      Purchased by: Private
Symptoms: Bacteraemia, Cardiac failure, Renal disorder, Culture positive, Neisseria test positive

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-06-06
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Prednisone 60 mg every other day at time of illness (unknown if taking at time of vaccination)
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Neisseria meningitidis serogroup Y isolated from blood, confirmed by culture (collection date: 6/8/2010)
CDC 'Split Type':

Write-up: Primary bacteremia, complications resulted in heart failure. (Note: Patient was on 60 mg prednisone every other day for kidney problems.)


Changed on 6/14/2018

VAERS ID: 397123 Before After
VAERS Form:1
Age:14.0
Sex:Male
Location:Wisconsin
Vaccinated:2007-07-31
Onset:2010-06-06
Submitted:2010-09-01
Entered:2010-09-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS AHAVB179AA / 1 RA / UN
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U2388AA / 1 LA / IM

Administered by: Private      Purchased by: Private
Symptoms: Bacteraemia, Cardiac failure, Renal disorder, Culture positive, Neisseria test positive

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-06-06
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Prednisone 60 mg every other day at time of illness (unknown if taking at time of vaccination)
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Neisseria meningitidis serogroup Y isolated from blood, confirmed by culture (collection date: 6/8/2010)
CDC 'Split Type':

Write-up: Primary bacteremia, complications resulted in heart failure. (Note: Patient was on 60 mg prednisone every other day for kidney problems.)


Changed on 8/14/2018

VAERS ID: 397123 Before After
VAERS Form:1
Age:14.0
Sex:Male
Location:Wisconsin
Vaccinated:2007-07-31
Onset:2010-06-06
Submitted:2010-09-01
Entered:2010-09-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS AHAVB179AA / 1 RA / UN
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U2388AA / 1 LA / IM

Administered by: Private      Purchased by: Private
Symptoms: Bacteraemia, Cardiac failure, Renal disorder, Culture positive, Neisseria test positive

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-06-06
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Prednisone 60 mg every other day at time of illness (unknown if taking at time of vaccination)
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Neisseria meningitidis serogroup Y isolated from blood, confirmed by culture (collection date: 6/8/2010)
CDC 'Split Type':

Write-up: Primary bacteremia, complications resulted in heart failure. (Note: Patient was on 60 mg prednisone every other day for kidney problems.)


Changed on 9/14/2018

VAERS ID: 397123 Before After
VAERS Form:1
Age:14.0
Sex:Male
Location:Wisconsin
Vaccinated:2007-07-31
Onset:2010-06-06
Submitted:2010-09-01
Entered:2010-09-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS AHAVB179AA / 1 RA / UN
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U2388AA / 1 LA / IM

Administered by: Private      Purchased by: Private
Symptoms: Bacteraemia, Cardiac failure, Renal disorder, Culture positive, Neisseria test positive

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-06-06
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Prednisone 60 mg every other day at time of illness (unknown if taking at time of vaccination)
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Neisseria meningitidis serogroup Y isolated from blood, confirmed by culture (collection date: 6/8/2010)
CDC 'Split Type':

Write-up: Primary bacteremia, complications resulted in heart failure. (Note: Patient was on 60 mg prednisone every other day for kidney problems.)


Changed on 10/14/2018

VAERS ID: 397123 Before After
VAERS Form:1
Age:14.0
Sex:Male
Location:Wisconsin
Vaccinated:2007-07-31
Onset:2010-06-06
Submitted:2010-09-01
Entered:2010-09-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS AHAVB179AA / 1 RA / UN
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U2388AA / 1 LA / IM

Administered by: Private      Purchased by: Private
Symptoms: Bacteraemia, Cardiac failure, Renal disorder, Culture positive, Neisseria test positive

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-06-06
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Prednisone 60 mg every other day at time of illness (unknown if taking at time of vaccination)
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Neisseria meningitidis serogroup Y isolated from blood, confirmed by culture (collection date: 6/8/2010)
CDC 'Split Type':

Write-up: Primary bacteremia, complications resulted in heart failure. (Note: Patient was on 60 mg prednisone every other day for kidney problems.)

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