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This is VAERS ID 133897

Case Details

VAERS ID: 133897 (history)  
Form: Version 1.0  
Age: 0.9  
Sex: Male  
Location: Florida  
Vaccinated:2000-02-10
Onset:2000-02-10
   Days after vaccination:0
Submitted: 2000-02-11
   Days after onset:1
Entered: 2000-07-20
   Days after submission:159
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 464305 / 3 LL / IM

Administered by: Private       Purchased by: Private
Symptoms: Cardiac arrest, Hypotonia
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Peripheral neuropathy (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2000-02-10
   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: Phenobarb
Current Illness: mild URI
Preexisting Conditions: possible seizure disorder
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt found to be cold & limp by mother who checked on him during his nap. Arrived in ER in asystole, DOA. 07/06/2000 Call from reporter today to say she finally obtained autopsy report and will fax it to us. 07/07/2000 autopsy report received from coroner. COD acute pulmonary decompensation due to DAD. Case complete.


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