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This is VAERS ID 539223

History of Changes from the VAERS Wayback Machine

First Appeared on 8/14/2014

VAERS ID: 539223
VAERS Form:
Age:12.0
Sex:Female
Location:Ohio
Vaccinated:2014-07-28
Onset:2014-07-28
Submitted:2014-08-07
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, Vomiting, Troponin T increased

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? 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.


Changed on 9/14/2014

VAERS ID: 539223 Before After
VAERS Form:
Age:12.0
Sex:Female
Location:Ohio
Vaccinated:2014-07-28
Onset:2014-07-28
Submitted:2014-08-07
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, Vomiting, Troponin T increased

Life Threatening? Yes
Birth Defect? No
Died? No Yes
   Date died:0000-00-00
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? 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.


Changed on 11/14/2014

VAERS ID: 539223 Before After
VAERS Form:
Age:12.0
Sex:Female
Location:Ohio
Vaccinated:2014-07-28
Onset:2014-07-28
Submitted:2014-08-07
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, Vomiting, Troponin T increased

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:0000-00-00 2014-08-25
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No Yes, days: (blank) 22     Extended hospital stay? 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.


Changed on 9/14/2017

VAERS ID: 539223 Before After
VAERS Form:(blank) 1
Age:12.0
Sex:Female
Location:Ohio
Vaccinated:2014-07-28
Onset:2014-07-28
Submitted:2014-08-07
Entered:2014-08-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U4798AA / 0 1 UN / IM
TDAP: TDAP (ADACEL) / SANOFI PASTEUR U4837AB / 0 1 UN / IM

Administered by: Private      Purchased by: Other
Symptoms: Cardiac failure, Lethargy, Myocarditis, Pyrexia, Vomiting, Troponin T increased

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2014-08-25
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 22     Extended hospital stay? 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.


Changed on 2/14/2018

VAERS ID: 539223 Before After
VAERS Form:1
Age:12.0
Sex:Female
Location:Ohio
Vaccinated:2014-07-28
Onset:2014-07-28
Submitted:2014-08-07
Entered:2014-08-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U4798AA / 1 UN / IM
TDAP: TDAP (ADACEL) / SANOFI PASTEUR U4837AB / 1 UN / IM

Administered by: Private      Purchased by: Other
Symptoms: Cardiac failure, Lethargy, Myocarditis, Pyrexia, Vomiting, Troponin T increased

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2014-08-25
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 22     Extended hospital stay? 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.


Changed on 6/14/2018

VAERS ID: 539223 Before After
VAERS Form:1
Age:12.0
Sex:Female
Location:Ohio
Vaccinated:2014-07-28
Onset:2014-07-28
Submitted:2014-08-07
Entered:2014-08-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U4798AA / 1 UN / IM
TDAP: TDAP (ADACEL) / SANOFI PASTEUR U4837AB / 1 UN / IM

Administered by: Private      Purchased by: Other
Symptoms: Cardiac failure, Lethargy, Myocarditis, Pyrexia, Vomiting, Troponin T increased

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2014-08-25
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 22     Extended hospital stay? 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.


Changed on 8/14/2018

VAERS ID: 539223 Before After
VAERS Form:1
Age:12.0
Sex:Female
Location:Ohio
Vaccinated:2014-07-28
Onset:2014-07-28
Submitted:2014-08-07
Entered:2014-08-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U4798AA / 1 UN / IM
TDAP: TDAP (ADACEL) / SANOFI PASTEUR U4837AB / 1 UN / IM

Administered by: Private      Purchased by: Other
Symptoms: Cardiac failure, Lethargy, Myocarditis, Pyrexia, Vomiting, Troponin T increased

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2014-08-25
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 22     Extended hospital stay? 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.


Changed on 9/14/2018

VAERS ID: 539223 Before After
VAERS Form:1
Age:12.0
Sex:Female
Location:Ohio
Vaccinated:2014-07-28
Onset:2014-07-28
Submitted:2014-08-07
Entered:2014-08-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U4798AA / 1 UN / IM
TDAP: TDAP (ADACEL) / SANOFI PASTEUR U4837AB / 1 UN / IM

Administered by: Private      Purchased by: Other
Symptoms: Cardiac failure, Lethargy, Myocarditis, Pyrexia, Vomiting, Troponin T increased

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2014-08-25
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 22     Extended hospital stay? 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.


Changed on 10/14/2018

VAERS ID: 539223 Before After
VAERS Form:1
Age:12.0
Sex:Female
Location:Ohio
Vaccinated:2014-07-28
Onset:2014-07-28
Submitted:2014-08-07
Entered:2014-08-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U4798AA / 1 UN / IM
TDAP: TDAP (ADACEL) / SANOFI PASTEUR U4837AB / 1 UN / IM

Administered by: Private      Purchased by: Other
Symptoms: Cardiac failure, Lethargy, Myocarditis, Pyrexia, Vomiting, Troponin T increased

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2014-08-25
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 22     Extended hospital stay? 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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