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This is VAERS ID 25569

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 25569
VAERS Form:
Age:16.0
Sex:Male
Location:Illinois
Vaccinated:1987-11-10
Onset:1987-12-29
Submitted:0000-00-00
Entered:1990-07-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MU: MUMPSVAX / MSD - / - - / -

Administered by: Private      Purchased by: Unknown
Symptoms: PAIN CHEST, ECG ABNORM, MYOCARDITIS

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: no relevant history
Allergies:
Diagnostic Lab Data: Autopsy revealed a grossly normal pancreas. Additional info. requested.
CDC 'Split Type':

Write-up: Pt vacc. /w Mumpsvax 1st dose in response to local mumps epidemic, 2 wks later he developed chest pain & abnormal ECG. Admitt to hospital & died 2 days later /p admission /w DX of myocarditis.MD could not establish a causal relationship.


Changed on 12/8/2009

VAERS ID: 25569 Before After
VAERS Form:
Age:16.0
Sex:Male
Location:Illinois
Vaccinated:1987-11-10
Onset:1987-12-29
Submitted:0000-00-00
Entered:1990-07-25 1990-07-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MU: MUMPSVAX MUMPS (MUMPSVAX I) / MSD MERCK & CO. INC. - / - - / -

Administered by: Private      Purchased by: Unknown
Symptoms: Chest pain, Electrocardiogram abnormal, Myocarditis, PAIN CHEST, ECG ABNORM, MYOCARDITIS

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: no relevant history
Allergies:
Diagnostic Lab Data: Autopsy revealed a grossly normal pancreas. Additional info. requested.
CDC 'Split Type': (blank) WAES90060971

Write-up: Pt vacc. /w Mumpsvax 1st dose in response to local mumps epidemic, 2 wks later he developed chest pain & abnormal ECG. Admitt to hospital & died 2 days later /p admission /w DX of myocarditis.MD could not establish a causal relationship.


Changed on 5/14/2017

VAERS ID: 25569 Before After
VAERS Form:
Age:16.0
Sex:Male
Location:Illinois
Vaccinated:1987-11-10
Onset:1987-12-29
Submitted:0000-00-00
Entered:1990-07-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MU: MUMPS (MUMPSVAX I) / MERCK & CO. INC. - / - - / -

Administered by: Private      Purchased by: Unknown
Symptoms: Chest pain, Electrocardiogram abnormal, Myocarditis

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness:
Preexisting Conditions: no relevant history
Allergies:
Diagnostic Lab Data: Autopsy revealed a grossly normal pancreas. Additional info. requested.
CDC 'Split Type': WAES90060971

Write-up: Pt vacc. /w Mumpsvax 1st dose in response to local mumps epidemic, 2 wks later he developed chest pain & abnormal ECG. Admitt to hospital & died 2 days later /p admission /w DX of myocarditis.MD could not establish a causal relationship.


Changed on 9/14/2017

VAERS ID: 25569 Before After
VAERS Form:(blank) 1
Age:16.0
Sex:Male
Location:Illinois
Vaccinated:1987-11-10
Onset:1987-12-29
Submitted:0000-00-00
Entered:1990-07-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MU: MUMPS (MUMPSVAX I) / MERCK & CO. INC. - / - UNK - / -

Administered by: Private      Purchased by: Unknown
Symptoms: Chest pain, Electrocardiogram abnormal, Myocarditis

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness:
Preexisting Conditions: no relevant history
Allergies:
Diagnostic Lab Data: Autopsy revealed a grossly normal pancreas. Additional info. requested.
CDC 'Split Type': WAES90060971

Write-up: Pt vacc. /w Mumpsvax 1st dose in response to local mumps epidemic, 2 wks later he developed chest pain & abnormal ECG. Admitt to hospital & died 2 days later /p admission /w DX of myocarditis.MD could not establish a causal relationship.


Changed on 2/14/2018

VAERS ID: 25569 Before After
VAERS Form:1
Age:16.0
Sex:Male
Location:Illinois
Vaccinated:1987-11-10
Onset:1987-12-29
Submitted:0000-00-00
Entered:1990-07-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MU: MUMPS (MUMPSVAX I) / MERCK & CO. INC. - / UNK - / -

Administered by: Private      Purchased by: Unknown
Symptoms: Chest pain, Electrocardiogram abnormal, Myocarditis

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness:
Preexisting Conditions: no relevant history
Allergies:
Diagnostic Lab Data: Autopsy revealed a grossly normal pancreas. Additional info. requested.
CDC 'Split Type': WAES90060971

Write-up: Pt vacc. /w Mumpsvax 1st dose in response to local mumps epidemic, 2 wks later he developed chest pain & abnormal ECG. Admitt to hospital & died 2 days later /p admission /w DX of myocarditis.MD could not establish a causal relationship.


Changed on 6/14/2018

VAERS ID: 25569 Before After
VAERS Form:1
Age:16.0
Sex:Male
Location:Illinois
Vaccinated:1987-11-10
Onset:1987-12-29
Submitted:0000-00-00
Entered:1990-07-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MU: MUMPS (MUMPSVAX I) / MERCK & CO. INC. - / UNK - / -

Administered by: Private      Purchased by: Unknown
Symptoms: Chest pain, Electrocardiogram abnormal, Myocarditis

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness:
Preexisting Conditions: no relevant history
Allergies:
Diagnostic Lab Data: Autopsy revealed a grossly normal pancreas. Additional info. requested.
CDC 'Split Type': WAES90060971

Write-up: Pt vacc. /w Mumpsvax 1st dose in response to local mumps epidemic, 2 wks later he developed chest pain & abnormal ECG. Admitt to hospital & died 2 days later /p admission /w DX of myocarditis.MD could not establish a causal relationship.


Changed on 8/14/2018

VAERS ID: 25569 Before After
VAERS Form:1
Age:16.0
Sex:Male
Location:Illinois
Vaccinated:1987-11-10
Onset:1987-12-29
Submitted:0000-00-00
Entered:1990-07-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MU: MUMPS (MUMPSVAX I) / MERCK & CO. INC. - / UNK - / -

Administered by: Private      Purchased by: Unknown
Symptoms: Chest pain, Electrocardiogram abnormal, Myocarditis

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness:
Preexisting Conditions: no relevant history
Allergies:
Diagnostic Lab Data: Autopsy revealed a grossly normal pancreas. Additional info. requested.
CDC 'Split Type': WAES90060971

Write-up: Pt vacc. /w Mumpsvax 1st dose in response to local mumps epidemic, 2 wks later he developed chest pain & abnormal ECG. Admitt to hospital & died 2 days later /p admission /w DX of myocarditis.MD could not establish a causal relationship.


Changed on 9/14/2018

VAERS ID: 25569 Before After
VAERS Form:1
Age:16.0
Sex:Male
Location:Illinois
Vaccinated:1987-11-10
Onset:1987-12-29
Submitted:0000-00-00
Entered:1990-07-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MU: MUMPS (MUMPSVAX I) / MERCK & CO. INC. - / UNK - / -

Administered by: Private      Purchased by: Unknown
Symptoms: Chest pain, Electrocardiogram abnormal, Myocarditis

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness:
Preexisting Conditions: no relevant history
Allergies:
Diagnostic Lab Data: Autopsy revealed a grossly normal pancreas. Additional info. requested.
CDC 'Split Type': WAES90060971

Write-up: Pt vacc. /w Mumpsvax 1st dose in response to local mumps epidemic, 2 wks later he developed chest pain & abnormal ECG. Admitt to hospital & died 2 days later /p admission /w DX of myocarditis.MD could not establish a causal relationship.


Changed on 10/14/2018

VAERS ID: 25569 Before After
VAERS Form:1
Age:16.0
Sex:Male
Location:Illinois
Vaccinated:1987-11-10
Onset:1987-12-29
Submitted:0000-00-00
Entered:1990-07-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MU: MUMPS (MUMPSVAX I) / MERCK & CO. INC. - / UNK - / -

Administered by: Private      Purchased by: Unknown
Symptoms: Chest pain, Electrocardiogram abnormal, Myocarditis

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness:
Preexisting Conditions: no relevant history
Allergies:
Diagnostic Lab Data: Autopsy revealed a grossly normal pancreas. Additional info. requested.
CDC 'Split Type': WAES90060971

Write-up: Pt vacc. /w Mumpsvax 1st dose in response to local mumps epidemic, 2 wks later he developed chest pain & abnormal ECG. Admitt to hospital & died 2 days later /p admission /w DX of myocarditis.MD could not establish a causal relationship.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=25569&WAYBACKHISTORY=ON


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