| VAERS ID: |
478441 (history) |
| Form: |
Version .0 |
| Age: |
0.1 |
| Sex: |
Male |
| Location: |
California |
| Vaccinated: | 2012-11-29 |
| Onset: | 2012-12-17 |
| Days after vaccination: | 18 |
| Submitted: |
2012-12-17 |
| Days after onset: | 0 |
| Entered: |
2012-12-17 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR |
C4292AA / 0 |
UN / IM |
| HIBV: HIB (ACTHIB) / SANOFI PASTEUR |
C4357AA / 0 |
UN / IM |
| PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH |
G10784 / 0 |
UN / IM |
| ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. |
0036AE / 0 |
- / PO |
Administered by: Private Purchased by: Private
Symptoms: Feeding disorder of infancy or early childhood,
Resuscitation,
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), Neonatal disorders (narrow), Hypotonic-hyporesponsive episode (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2012-12-17
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: Probiotics
Current Illness: None
Preexisting Conditions: Gassy baby on hypoallergenic formula
Allergies:
Diagnostic Lab Data: Done at medical center
CDC Split Type:
Write-up: 12/16/12 baby fed less well. 12/17/12 found unresponsive. Did not respond to resuscitation efforts. |
