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From the 9/17/2021 release of VAERS data:

This is VAERS ID 289100



Case Details

VAERS ID: 289100 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: Illinois  
Vaccinated:2007-08-23
Onset:2007-08-24
   Days after vaccination:1
Submitted: 2007-08-27
   Days after onset:3
Entered: 2007-08-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B115AA / 1 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B53981A / 1 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0508U / 1 MO / PO

Administered by: Unknown       Purchased by: Unknown
Symptoms: Death, Developmental delay, Failure to thrive
SMQs:, Neonatal disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2007-08-25
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: none
Preexisting Conditions: Microcephalus, underweight BIRTH HX: 38-wk emergency c-section due to deceleration, nuchal cord & decreased amniotic fluid. 6 days in NICU. Parents are 1st cousins (+ consanguinity). Had 5yo sibling deceased w/similar s/s & seizure disorder, apnea & flat head.
Allergies:
Diagnostic Lab Data: LABS: MRI at birth showed areas of hypoplasia of corpus callosum. Echocardiogram done during resuscitation revealed very wide QRS & bradycardia which progressed to EMD w/o any mechanical cardiac funation. Abdomen KUB revealed nonspecific nonobstructive bowel gas patter w/paucity of small bowel gas. CXR WNL. Blood c/s (+) for bacillus species but may have been contaminant.
CDC Split Type:

Write-up: Patient died two days after receiving vaccines. Infant had multiple problems including failure to thrive, and developmental delays. Was admitted with complete heart block. 8/28/07 Spoke w/the reporter on this case who will provide medical records from clinic & hospital as well as a copy of the Death Certificate. No autopsy was done. Reporter stated this child had multiple medical problems & was being followed by several clinic specialists including geneticist. Sibling of this child also had multiple problems & expired at unknown time. 9/7/07 Reviewed medical records & Death Certifiate from reporter. COD stated as complete heart block w/microcephaly & failure to thrive as contributing factors. Vax record confirms dose & Lot # of all vax as reported. Had microcephaly, hypertonia & contractures of UEs noted on d/c from birth hospital. Referred by birth hospital to Easter Seals for developmental therapy eval 7/07. Medical records show that on day of vax had cough & sneeze along w/very slow feeding & poor growth noted. Referred for feeding eval. PCP records indicate patient on home monitor. Neuro, Genetic & Cardio consults. Very slowly gained weight & remained significantly underweight. Genetics eval done 7/07. Developmental delay. Cardiac consult on day of death reveals patient admitted 8/24 for diarrhea & poor feeding then developed slow heart rate & complete heart block. FINAL DX: complete heart block, microcephaly & failure to thrive.


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