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This is VAERS ID 111504

Case Details

VAERS ID: 111504 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Female  
Location: Michigan  
Vaccinated:1998-05-18
Onset:1998-05-19
   Days after vaccination:1
Submitted: 1998-06-02
   Days after onset:14
Entered: 1998-06-08
   Days after submission:6
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 451497 / 1 LL / IM
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 2420A2 / 2 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 44779D / 1 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. M1351 / 1 RL / SC

Administered by: Private       Purchased by: Private
Symptoms: Atelectasis, Cardiac arrest, Lung disorder, Pneumothorax
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), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1998-05-19
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: mild URI
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt presented to ER in full arrest p/a nap 19MAY98 1 day p/vax;


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