| VAERS ID: |
459641 (history) |
| Form: |
Version 1.0 |
| Age: |
19.0 |
| Sex: |
Male |
| Location: |
Ohio |
| Vaccinated: | 2012-01-19 |
| Onset: | 2012-01-28 |
| Days after vaccination: | 9 |
| Submitted: |
2012-07-13 |
| Days after onset: | 166 |
| Entered: |
2012-07-19 |
| Days after submission: | 6 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS |
AHBVC010AB / 3 |
LA / UN |
| HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS |
AHAVB532AA / 1 |
RA / UN |
| IPV: POLIO VIRUS, INACT. (POLIOVAX) / SANOFI PASTEUR |
11451 / 1 |
LA / UN |
| TD: TD ADSORBED (NO BRAND NAME) / SANOFI PASTEUR |
U3399CA / 1 |
LA / UN |
| VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. |
0342AA / 1 |
RA / UN |
Administered by: Public Purchased by: Public
Symptoms: Congestive cardiomyopathy,
Death,
Excessive exercise,
Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (narrow), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2012-01-28
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: None known
Allergies:
Diagnostic Lab Data: Death certificate - cause of death - dilated cardiomyopathy, excessive exercise on treadmill
CDC Split Type:
Write-up: No previous problems known. Pt was found unresponsive in rec room of home with treadmill running. |
