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This is VAERS ID 113301

Case Details

VAERS ID: 113301 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: North Carolina  
Vaccinated:1998-04-22
Onset:1998-04-25
   Days after vaccination:3
Submitted: 1998-07-01
   Days after onset:67
Entered: 1998-08-10
   Days after submission:40
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES 7C91935 / 1 LL / -
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 2392AZ / 2 RL / -
HIBV: HIB (HIBTITER) / PFIZER/WYETH 4165RH / 1 LL / -
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. 41295 / 1 RL / -

Administered by: Private       Purchased by: Public
Symptoms: Anorexia, Apnoea, Dyspnoea, Infection, Influenza, Pneumonia, Unevaluable event
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1998-04-25
   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: Pediazole
Current Illness: Pneumonia
Preexisting Conditions: Prematurity
Allergies:
Diagnostic Lab Data: On 4/24/98 grandparents noted pt. holding his breath. On 4/25/98, pt. not breathing. Resuscitation not successful. Post mortem-Pneumonia/H.Influenza.
CDC Split Type:

Write-up: Pt. recv. vax. on 04/22/98. On 4/24/98, pt. slept between his two grandparents in the same bed. On 4/25/98, grandparents awoke and noted that the infant was no longer breathing. EMS called. Pt. taken to hospital.


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