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This is VAERS ID 113425

Case Details

VAERS ID: 113425 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: Virginia  
Vaccinated:1998-07-23
Onset:1998-07-25
   Days after vaccination:2
Submitted: 1998-08-07
   Days after onset:13
Entered: 1998-08-14
   Days after submission:7
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 453845 / 1 LL / IM
HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC. 0435H / 2 RL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M010RN / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0291 / 1 LL / SC

Administered by: Private       Purchased by: Private
Symptoms: Cardiac arrest, Cyanosis, Sudden infant death syndrome
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), 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), Neonatal disorders (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1998-07-25
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: 7/27/98-Autopsy by VA Chief Medical Examiner, Richmond, VA
CDC Split Type:

Write-up: Pt recv vax on 7/23/98; on 7/25/98 pt found blue in bed. Pt exp cardiopulmonary arrest; autopsy c/w SIDS.


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