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This is VAERS ID 416107

Case Details

VAERS ID: 416107 (history)  
Form: Version 1.0  
Age: 18.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2005-07-12
Onset:2011-01-13
   Days after vaccination:2011
Submitted: 2011-02-03
   Days after onset:21
Entered: 2011-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U1639AA / 1 LA / IM

Administered by: Unknown       Purchased by: Other
Symptoms: CSF culture positive, Death, Endotracheal intubation, Gram stain, Hypoaesthesia, Lacrimal haemorrhage, Meningitis, Meningococcal bacteraemia, Neisseria test positive, Pyrexia, Rash
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Peripheral neuropathy (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious meningitis (narrow), Lacrimal disorders (narrow), Hypersensitivity (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Sepsis (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2011-01-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: No medications
Current Illness: Unknown
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Neisseria meningitidis serogroup C confirmed by culture in cerebrospinal fluid sample. Cause of death: meningococcemia and meningitis.
CDC Split Type: 473442WI00010

Write-up: Non-specific symptoms began 1/12/2011, progressed to rash, fever, numbness in arms/legs 1/13. Taken to Emergency Department, experienced blood in tears, was intubated and crashed within 2 hours of arrival to hospital. Cerebrospinal fluid was collected and showed Gram-negative diplococci. Culture later tested positive for Neisseria meningitidis serogroup C.


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