National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

This is VAERS ID 416107

History of Changes from the VAERS Wayback Machine

First Appeared on 2/4/2011

VAERS ID: 416107
VAERS Form:
Age:18.0
Sex:Male
Location:Wisconsin
Vaccinated:2005-07-12
Onset:2011-01-13
Submitted:2011-02-03
Entered:2011-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U1639AA / 0 LA / IM

Administered by: Unknown      Purchased by: Other
Symptoms: CSF culture positive, Death, Gram stain, Hypoaesthesia, Meningitis, Pyrexia, Rash, Meningococcal bacteraemia, Endotracheal intubation, Lacrimal haemorrhage, Neisseria test positive

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2011-01-13
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? 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.


Changed on 4/13/2011

VAERS ID: 416107 Before After
VAERS Form:
Age:18.0
Sex:Male
Location:Wisconsin
Vaccinated:2005-07-12
Onset:2011-01-13
Submitted:2011-02-03
Entered:2011-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U1639AA / 0 LA / IM

Administered by: Unknown      Purchased by: Other
Symptoms: Activated partial thromboplastin time prolonged, Blood creatinine increased, Blood urea increased, Chills, CSF culture positive, CSF protein normal, Death, Disseminated intravascular coagulation, Dyspnoea, Glomerular filtration rate increased, Gram stain, Hypoaesthesia, Loss of consciousness, Lumbar puncture, Meningitis, Meningitis meningococcal, Neutrophil count decreased, Pallor, Petechiae, Platelet count decreased, Poor peripheral circulation, Pulmonary oedema, Pyrexia, Rash, Septic shock, Visual impairment, Vomiting, White blood cell count decreased, CSF glucose increased, Monocyte percentage decreased, Meningococcal bacteraemia, Endotracheal intubation, Lacrimal haemorrhage, Neisseria test positive

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2011-01-13
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? 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.


Changed on 5/13/2011

VAERS ID: 416107 Before After
VAERS Form:
Age:18.0
Sex:Male
Location:Wisconsin
Vaccinated:2005-07-12
Onset:2011-01-13
Submitted:2011-02-03
Entered:2011-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U1639AA / 0 LA / IM

Administered by: Unknown      Purchased by: Other
Symptoms: Activated partial thromboplastin time prolonged, Blood creatinine increased, Blood urea increased, Chills, CSF culture positive, CSF protein normal, Death, Disseminated intravascular coagulation, Dyspnoea, Glomerular filtration rate increased, Gram stain, Hypoaesthesia, Loss of consciousness, Lumbar puncture, Meningitis, Meningitis meningococcal, Neutrophil count decreased, Pallor, Petechiae, Platelet count decreased, Poor peripheral circulation, Pulmonary oedema, Pyrexia, Rash, Septic shock, Visual impairment, Vomiting, White blood cell count decreased, CSF glucose increased, Monocyte percentage decreased, Meningococcal bacteraemia, Endotracheal intubation, Lacrimal haemorrhage, Neisseria test positive

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2011-01-13
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? 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.


Changed on 6/14/2014

VAERS ID: 416107 Before After
VAERS Form:
Age:18.0
Sex:Male
Location:Wisconsin
Vaccinated:2005-07-12
Onset:2011-01-13
Submitted:2011-02-03
Entered:2011-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U1639AA / 0 LA / IM

Administered by: Unknown      Purchased by: Other
Symptoms: CSF culture positive, Death, Gram stain, Hypoaesthesia, Meningitis, Pyrexia, Rash, Meningococcal bacteraemia, Endotracheal intubation, Lacrimal haemorrhage, Neisseria test positive

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2011-01-13
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? 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.


Changed on 4/14/2017

VAERS ID: 416107 Before After
VAERS Form:
Age:18.0
Sex:Male
Location:Wisconsin
Vaccinated:2005-07-12
Onset:2011-01-13
Submitted:2011-02-03
Entered:2011-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U1639AA / 0 LA / IM

Administered by: Unknown      Purchased by: Other
Symptoms: CSF culture positive, Death, Gram stain, Hypoaesthesia, Meningitis, Pyrexia, Rash, Meningococcal bacteraemia, Endotracheal intubation, Lacrimal haemorrhage, Neisseria test positive

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2011-01-13
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? 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.


Changed on 9/14/2017

VAERS ID: 416107 Before After
VAERS Form:(blank) 1
Age:18.0
Sex:Male
Location:Wisconsin
Vaccinated:2005-07-12
Onset:2011-01-13
Submitted:2011-02-03
Entered:2011-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U1639AA / 0 1 LA / IM

Administered by: Unknown      Purchased by: Other
Symptoms: CSF culture positive, Death, Gram stain, Hypoaesthesia, Meningitis, Pyrexia, Rash, Meningococcal bacteraemia, Endotracheal intubation, Lacrimal haemorrhage, Neisseria test positive

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2011-01-13
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? 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.


Changed on 2/14/2018

VAERS ID: 416107 Before After
VAERS Form:1
Age:18.0
Sex:Male
Location:Wisconsin
Vaccinated:2005-07-12
Onset:2011-01-13
Submitted:2011-02-03
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, Gram stain, Hypoaesthesia, Meningitis, Pyrexia, Rash, Meningococcal bacteraemia, Endotracheal intubation, Lacrimal haemorrhage, Neisseria test positive

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2011-01-13
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? 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.


Changed on 6/14/2018

VAERS ID: 416107 Before After
VAERS Form:1
Age:18.0
Sex:Male
Location:Wisconsin
Vaccinated:2005-07-12
Onset:2011-01-13
Submitted:2011-02-03
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, Gram stain, Hypoaesthesia, Meningitis, Pyrexia, Rash, Meningococcal bacteraemia, Endotracheal intubation, Lacrimal haemorrhage, Neisseria test positive

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2011-01-13
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? 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.


Changed on 8/14/2018

VAERS ID: 416107 Before After
VAERS Form:1
Age:18.0
Sex:Male
Location:Wisconsin
Vaccinated:2005-07-12
Onset:2011-01-13
Submitted:2011-02-03
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, Gram stain, Hypoaesthesia, Meningitis, Pyrexia, Rash, Meningococcal bacteraemia, Endotracheal intubation, Lacrimal haemorrhage, Neisseria test positive

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2011-01-13
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? 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.


Changed on 9/14/2018

VAERS ID: 416107 Before After
VAERS Form:1
Age:18.0
Sex:Male
Location:Wisconsin
Vaccinated:2005-07-12
Onset:2011-01-13
Submitted:2011-02-03
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, Gram stain, Hypoaesthesia, Meningitis, Pyrexia, Rash, Meningococcal bacteraemia, Endotracheal intubation, Lacrimal haemorrhage, Neisseria test positive

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2011-01-13
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? 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.


Changed on 10/14/2018

VAERS ID: 416107 Before After
VAERS Form:1
Age:18.0
Sex:Male
Location:Wisconsin
Vaccinated:2005-07-12
Onset:2011-01-13
Submitted:2011-02-03
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, Gram stain, Hypoaesthesia, Meningitis, Pyrexia, Rash, Meningococcal bacteraemia, Endotracheal intubation, Lacrimal haemorrhage, Neisseria test positive

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2011-01-13
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? 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.

New Search

Link To This Search Result:

https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=416107&WAYBACKHISTORY=ON


Copyright © 2019 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166