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This is VAERS ID 416374

History of Changes from the VAERS Wayback Machine

First Appeared on 3/11/2011

VAERS ID: 416374
VAERS Form:
Age:15.0
Sex:Male
Location:New Jersey
Vaccinated:2009-08-17
Onset:2011-01-21
Submitted:2011-02-04
Entered:2011-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U2818AA / - LA / IM

Administered by: Private      Purchased by: Private
Symptoms: Blood culture positive, Death, Intensive care, Meningococcal sepsis, Petechiae, Pyrexia, Vomiting

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-23
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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.


Changed on 4/13/2011

VAERS ID: 416374 Before After
VAERS Form:
Age:15.0
Sex:Male
Location:New Jersey
Vaccinated:2009-08-17
Onset:2011-01-21
Submitted:2011-02-04
Entered:2011-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U2818AA / - LA / IM

Administered by: Private      Purchased by: Private
Symptoms: Activated partial thromboplastin time prolonged, Aspartate aminotransferase increased, Blood creatinine increased, Blood culture positive, Blood glucose decreased, Blood lactic acid increased, Blood urea increased, Bradycardia, Death, Diarrhoea, Disseminated intravascular coagulation, Ecchymosis, Fibrin D dimer increased, Headache, Hypotension, Intensive care, International normalised ratio increased, Lactic acidosis, Meningitis meningococcal, Meningococcal sepsis, Metabolic acidosis, Multi-organ failure, Nausea, Oliguria, Pain in extremity, Peripheral coldness, Petechiae, Platelet count decreased, Purpura fulminans, Pyrexia, Renal failure acute, Septic shock, Tachycardia, Thrombocytopenia, Vomiting, White blood cell count increased, Left ventricular dysfunction, Left ventricular hypertrophy, Bacterial sepsis, Echocardiogram abnormal, Endotracheal intubation, Capillary nail refill test abnormal, Neisseria test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-23
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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.


Changed on 5/13/2011

VAERS ID: 416374 Before After
VAERS Form:
Age:15.0
Sex:Male
Location:New Jersey
Vaccinated:2009-08-17
Onset:2011-01-21
Submitted:2011-02-04
Entered:2011-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U2818AA / - LA / IM

Administered by: Private      Purchased by: Private
Symptoms: Activated partial thromboplastin time prolonged, Aspartate aminotransferase increased, Blood creatinine increased, Blood culture positive, Blood glucose decreased, Blood lactic acid increased, Blood urea increased, Bradycardia, Death, Diarrhoea, Disseminated intravascular coagulation, Ecchymosis, Fibrin D dimer increased, Headache, Hypotension, Intensive care, International normalised ratio increased, Lactic acidosis, Meningitis meningococcal, Meningococcal sepsis, Metabolic acidosis, Multi-organ failure, Nausea, Oliguria, Pain in extremity, Peripheral coldness, Petechiae, Platelet count decreased, Purpura fulminans, Pyrexia, Renal failure acute, Septic shock, Tachycardia, Thrombocytopenia, Vomiting, White blood cell count increased, Left ventricular dysfunction, Left ventricular hypertrophy, Bacterial sepsis, Echocardiogram abnormal, Endotracheal intubation, Capillary nail refill test abnormal, Neisseria test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-23
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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.


Changed on 9/14/2017

VAERS ID: 416374 Before After
VAERS Form:(blank) 1
Age:15.0
Sex:Male
Location:New Jersey
Vaccinated:2009-08-17
Onset:2011-01-21
Submitted:2011-02-04
Entered:2011-02-08
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-23
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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.


Changed on 2/14/2018

VAERS ID: 416374 Before After
VAERS Form:1
Age:15.0
Sex:Male
Location:New Jersey
Vaccinated:2009-08-17
Onset:2011-01-21
Submitted:2011-02-04
Entered:2011-02-08
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-23
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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.


Changed on 6/14/2018

VAERS ID: 416374 Before After
VAERS Form:1
Age:15.0
Sex:Male
Location:New Jersey
Vaccinated:2009-08-17
Onset:2011-01-21
Submitted:2011-02-04
Entered:2011-02-08
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-23
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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.


Changed on 8/14/2018

VAERS ID: 416374 Before After
VAERS Form:1
Age:15.0
Sex:Male
Location:New Jersey
Vaccinated:2009-08-17
Onset:2011-01-21
Submitted:2011-02-04
Entered:2011-02-08
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-23
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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.


Changed on 9/14/2018

VAERS ID: 416374 Before After
VAERS Form:1
Age:15.0
Sex:Male
Location:New Jersey
Vaccinated:2009-08-17
Onset:2011-01-21
Submitted:2011-02-04
Entered:2011-02-08
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-23
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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.


Changed on 10/14/2018

VAERS ID: 416374 Before After
VAERS Form:1
Age:15.0
Sex:Male
Location:New Jersey
Vaccinated:2009-08-17
Onset:2011-01-21
Submitted:2011-02-04
Entered:2011-02-08
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-23
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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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