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This is VAERS ID 162446

Case Details

VAERS ID: 162446 (history)  
Form: Version 1.0  
Age: 57.0  
Sex: Male  
Location: Maryland  
Vaccinated:2000-11-01
Onset:2000-11-03
   Days after vaccination:2
Submitted: 2000-11-17
   Days after onset:14
Entered: 2000-11-22
   Days after submission:5
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEPA: HEP A (HAVRIX) / SMITHKLINE BEECHAM VHA67036 / 1 - / IM
TD: TD ADSORBED (NO BRAND NAME) / CONNAUGHT LABORATORIES U0193AA / 1 - / IM

Administered by: Public       Purchased by: Private
Symptoms: Bundle branch block, Disseminated intravascular coagulation, Lethargy, Pyrexia, Skin discolouration
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Conduction defects (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2000-11-05
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: High blood pressure
Allergies:
Diagnostic Lab Data:
CDC Split Type: U2000008210

Write-up: Reportedly on 11/3/00, the pt presented to the hospital ER with lethargy, fever and skin the color of purple. He was transferred to a university hospital on 11/4/00. The pt went into organ failure and disseminated intravascular coagulation. The pt died on 11/5/00, the pt''s wife refused an autopsy.


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