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This is VAERS ID 582853

Case Details

VAERS ID: 582853 (history)  
Form: Version 1.0  
Age: 17.0  
Sex: Male  
Location: Arizona  
Vaccinated:2015-06-08
Onset:2015-06-10
   Days after vaccination:2
Submitted: 2015-06-23
   Days after onset:13
Entered: 2015-06-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR A14097 / 2 LA / UN

Administered by: Private       Purchased by: Private
Symptoms: Adenoidal hypertrophy, Computerised tomogram abnormal, Intensive care, Mechanical ventilation, Mononucleosis heterophile test positive, Pharyngeal oedema, Tonsillar hypertrophy
SMQs:, Anaphylactic reaction (broad), Angioedema (narrow), Oropharyngeal allergic conditions (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Hypersensitivity (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2016-04-12
   Days after onset: 307
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, 301 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Azithromycin; Steroid
Current Illness: Tonsillitis
Preexisting Conditions: Amoxicillin allergy
Allergies:
Diagnostic Lab Data: (+) Mono test at urgent care 6/10/15; (+) tonsil/adenoid/throat swelling on CT 6/13/15
CDC Split Type:

Write-up: Pt. was mildly ill with tonsillitis when vaccine given. 2 days later went to urgent care for worsening (throat swelling). 2 days later went to hospital ED for throat swelling and transported to another hospital. In PICU now x 3 days on ventilator. They think severe EBV infection, but unsure.


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