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This is VAERS ID 867687

History of Changes from the VAERS Wayback Machine

First Appeared on 4/14/2020

VAERS ID: 867687
VAERS Form:2
Age:1.0
Sex:Male
Location:California
Vaccinated:2019-10-09
Onset:2020-01-17
Submitted:0000-00-00
Entered:2020-04-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU4: INFLUENZA (SEASONAL) (FLUARIX QUADRIVALENT) / GLAXOSMITHKLINE BIOLOGICALS - / UNK - / -
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS - / UNK - / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. - / UNK - / -
MMRV: MEASLES + MUMPS + RUBELLA + VARICELLA (PROQUAD) / MERCK & CO. INC. - / UNK - / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. - / UNK - / -

Administered by: Private      Purchased by: ??
Symptoms: Death, Encephalitis, Respiratory failure, CSF test, Albumin CSF, CSF immunoglobulin G index, Hypoxic-ischaemic encephalopathy, Magnetic resonance imaging

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2020-01-25
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 8     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: MRI CSF, Albumin CSF, IgG CSF encephalitis, meningitis panel
CDC 'Split Type':

Write-up: Acute bilateral cerebellitis, respiratory failure, anoxic encephalopathy, death. Presented to Hospital on 1/17/2020, expired 1/25/2020.


Changed on 12/24/2020

VAERS ID: 867687 Before After
VAERS Form:2
Age:1.0
Sex:Male
Location:California
Vaccinated:2019-10-09
Onset:2020-01-17
Submitted:0000-00-00
Entered:2020-04-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU4: INFLUENZA (SEASONAL) (FLUARIX QUADRIVALENT) / GLAXOSMITHKLINE BIOLOGICALS - / UNK - / -
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS - / UNK - / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. - / UNK - / -
MMRV: MEASLES + MUMPS + RUBELLA + VARICELLA (PROQUAD) / MERCK & CO. INC. - / UNK - / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. - / UNK - / -

Administered by: Private      Purchased by: ??
Symptoms: Death, Encephalitis, Respiratory failure, CSF test, Albumin CSF, CSF immunoglobulin G index, Hypoxic-ischaemic encephalopathy, Magnetic resonance imaging

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2020-01-25
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 8     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: MRI CSF, Albumin CSF, IgG CSF encephalitis, meningitis panel
CDC 'Split Type':

Write-up: Acute bilateral cerebellitis, respiratory failure, anoxic encephalopathy, death. Presented to Hospital on 1/17/2020, expired 1/25/2020.


Changed on 12/30/2020

VAERS ID: 867687 Before After
VAERS Form:2
Age:1.0
Sex:Male
Location:California
Vaccinated:2019-10-09
Onset:2020-01-17
Submitted:0000-00-00
Entered:2020-04-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU4: INFLUENZA (SEASONAL) (FLUARIX QUADRIVALENT) / GLAXOSMITHKLINE BIOLOGICALS - / UNK - / -
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS - / UNK - / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. - / UNK - / -
MMRV: MEASLES + MUMPS + RUBELLA + VARICELLA (PROQUAD) / MERCK & CO. INC. - / UNK - / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. - / UNK - / -

Administered by: Private      Purchased by: ??
Symptoms: Death, Encephalitis, Respiratory failure, CSF test, Albumin CSF, CSF immunoglobulin G index, Hypoxic-ischaemic encephalopathy, Magnetic resonance imaging

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2020-01-25
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 8     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: MRI CSF, Albumin CSF, IgG CSF encephalitis, meningitis panel
CDC 'Split Type':

Write-up: Acute bilateral cerebellitis, respiratory failure, anoxic encephalopathy, death. Presented to Hospital on 1/17/2020, expired 1/25/2020.


Changed on 5/7/2021

VAERS ID: 867687 Before After
VAERS Form:2
Age:1.0
Sex:Male
Location:California
Vaccinated:2019-10-09
Onset:2020-01-17
Submitted:0000-00-00
Entered:2020-04-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU4: INFLUENZA (SEASONAL) (FLUARIX QUADRIVALENT) / GLAXOSMITHKLINE BIOLOGICALS - / UNK - / -
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS - / UNK - / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. - / UNK - / -
MMRV: MEASLES + MUMPS + RUBELLA + VARICELLA (PROQUAD) / MERCK & CO. INC. - / UNK - / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. - / UNK - / -

Administered by: Private      Purchased by: ??
Symptoms: Death, Encephalitis, Respiratory failure, CSF test, Albumin CSF, CSF immunoglobulin G index, Hypoxic-ischaemic encephalopathy, Magnetic resonance imaging

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2020-01-25
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 8     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: MRI CSF, Albumin CSF, IgG CSF encephalitis, meningitis panel
CDC 'Split Type':

Write-up: Acute bilateral cerebellitis, respiratory failure, anoxic encephalopathy, death. Presented to Hospital on 1/17/2020, expired 1/25/2020.


Changed on 5/14/2021

VAERS ID: 867687 Before After
VAERS Form:2
Age:1.0
Sex:Male
Location:California
Vaccinated:2019-10-09
Onset:2020-01-17
Submitted:0000-00-00
Entered:2020-04-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU4: INFLUENZA (SEASONAL) (FLUARIX QUADRIVALENT) / GLAXOSMITHKLINE BIOLOGICALS - / UNK - / -
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS - / UNK - / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. - / UNK - / -
MMRV: MEASLES + MUMPS + RUBELLA + VARICELLA (PROQUAD) / MERCK & CO. INC. - / UNK - / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. - / UNK - / -

Administered by: Private      Purchased by: ??
Symptoms: Death, Encephalitis, Respiratory failure, CSF test, Albumin CSF, CSF immunoglobulin G index, Hypoxic-ischaemic encephalopathy, Magnetic resonance imaging

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2020-01-25
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 8     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: MRI CSF, Albumin CSF, IgG CSF encephalitis, meningitis panel
CDC 'Split Type':

Write-up: Acute bilateral cerebellitis, respiratory failure, anoxic encephalopathy, death. Presented to Hospital on 1/17/2020, expired 1/25/2020.

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