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This is VAERS ID 114925

Case Details

VAERS ID: 114925 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: Michigan  
Vaccinated:1998-09-23
Onset:1998-09-25
   Days after vaccination:2
Submitted: 1998-10-07
   Days after onset:12
Entered: 1998-10-13
   Days after submission:6
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 453844 / 1 RL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M240RK / 1 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N10351 / 1 LL / SC

Administered by: Private       Purchased by: Private
Symptoms: Agitation, Anaemia, Apnoea, Cardiac arrest, Dyspnoea, Gaze palsy, Laboratory test abnormal, Respiratory alkalosis
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Asthma/bronchospasm (broad), Haematopoietic erythropenia (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Ocular motility disorders (narrow), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1998-09-26
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE but was 36wk SGA infant
Allergies:
Diagnostic Lab Data: hgb 3.0;bld PH 6.5;NA140;cl 113;plts 91;K+ 7.0;co2 6.5;
CDC Split Type:

Write-up: pt recv vax 23SEP98 & was fussy 25SEP98;26SEP98 early hr of AM pt noted to be gasping w/eyes deviated;unsuccessful full resuscitation on immed arrival @ ER;pt was in cardiorespiratory arrest;


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