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This is VAERS ID 416374

Case Details

VAERS ID: 416374 (history)  
Form: Version 1.0  
Age: 15.0  
Sex: Male  
Location: New Jersey  
Vaccinated:2009-08-17
Onset:2011-01-21
   Days after vaccination:522
Submitted: 2011-02-04
   Days after onset:14
Entered: 2011-02-08
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U2818AA / UNK LA / IM

Administered by: Private       Purchased by: Private
Symptoms: Blood culture positive, Death, Intensive care, Meningococcal sepsis, Petechiae, Pyrexia, Vomiting
SMQs:, Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Sepsis (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2011-01-23
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Not reported
Allergies:
Diagnostic Lab Data:
CDC Split Type: 201100459

Write-up: Initial case received from a physician on 01 February 2011. A 17-year-old male patient received an intramuscular injection of MENACTRA (lot number U2818AA) on 17 August 2009. On 21 January 2011 he presented to the emergency room with fever, vomiting, and petechia, and was diagnosed with meningococcal septicemia. He was transferred to the intensive care unit in critical condition, and died on 23 January 2011. Per the reporter, the patient had undergone blood cultures which were positive for meningococcal strain C. No medical history or concomitant medications were reported; the patient was not ill at the time of vaccination. Documents held by sender: None.


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