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This is VAERS ID 539223

(NOTE: This result is from the 9/14/2014 version of the VAERS database)

Case Details

VAERS ID: 539223 (history)  
Form: Version .0  
Age: 12.0  
Sex: Female  
Location: Ohio  
Vaccinated:2014-07-28
Onset:2014-07-28
   Days after vaccination:0
Submitted: 2014-08-07
   Days after onset:10
Entered: 2014-08-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U4798AA / 0 UN / IM
TDAP: TDAP (ADACEL) / SANOFI PASTEUR U4837AB / 0 UN / IM

Administered by: Private       Purchased by: Other
Symptoms: Cardiac failure, Lethargy, Myocarditis, Pyrexia, Troponin T increased, Vomiting
SMQs:, Cardiac failure (narrow), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: None reported.
Preexisting Conditions: None elicited.
Allergies:
Diagnostic Lab Data: 8/3/2014 08:00 Troponin T: 10.090 (H)
CDC Split Type:

Write-up: Fever, lethargy. Later developed vomiting and went into heart failure. Preliminary diagnosis of Acute myocarditis.


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https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20140914&IDNUMBER=539223


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