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This is VAERS ID 108656

Case Details

VAERS ID: 108656 (history)  
Form: Version 1.0  
Age: 0.3  
Sex: Male  
Location: New York  
Vaccinated:1998-02-27
Onset:1998-03-05
   Days after vaccination:6
Submitted: 1998-03-10
   Days after onset:5
Entered: 1998-03-17
   Days after submission:7
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES 0907380 / 2 - / IM L
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 2500A2 / 2 - / IM L
HIBV: HIB (PROHIBIT) / CONNAUGHT LABORATORIES 0915240 / 2 - / IM L
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. M0939 / 2 - / IM L

Administered by: Private       Purchased by: Private
Symptoms: Cardiac arrest
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1998-03-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: Respigam
Current Illness: NONE
Preexisting Conditions: prematurity-hx ROS/anemia
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: pt expired on 5MAR98 presented to ER in full C-R arrest;


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