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This is VAERS ID 289100

History of Changes from the VAERS Wayback Machine

First Appeared on 12/31/2007

VAERS ID: 289100
VAERS Form:
Age:0.2
Sex:Male
Location:Illinois
Vaccinated:2007-08-23
Onset:2007-08-24
Submitted:2007-08-27
Entered:2007-08-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B115AA / 0 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 0 RL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B53981A / 0 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0508U / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Atrioventricular block complete, Blood culture, Bradycardia, Cerebellar hypoplasia, Chest X-ray normal

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-25
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: none
Preexisting Conditions: Microcephalus, underweight
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
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.


Changed on 12/8/2009

VAERS ID: 289100 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:Illinois
Vaccinated:2007-08-23
Onset:2007-08-24
Submitted:2007-08-27
Entered:2007-08-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B115AA / 0 LL / IM
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B115AA / 0 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 0 RL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B53981A / 0 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0508U / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Atrioventricular block complete, Blood culture, Bradycardia, Cerebellar hypoplasia, Chest X-ray normal, Cough, Death, Developmental delay, Diarrhoea, Failure to thrive, Feeding disorder neonatal, Hypertonia, Nuclear magnetic resonance imaging brain abnormal, Sneezing, Urinary system X-ray, Electromechanical dissociation, Echocardiogram abnormal, Muscle contracture

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-25
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: 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
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.


Changed on 3/2/2010

VAERS ID: 289100 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:Illinois
Vaccinated:2007-08-23
Onset:2007-08-24
Submitted:2007-08-27
Entered:2007-08-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B115AA / 0 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 0 RL / IM
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC B53981A / 0 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0508U / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Atrioventricular block complete, Blood culture, Bradycardia, Cerebellar hypoplasia, Chest X-ray normal, Cough, Death, Developmental delay, Diarrhoea, Failure to thrive, Feeding disorder neonatal, Hypertonia, Nuclear magnetic resonance imaging brain abnormal, Sneezing, Urinary system X-ray, Electromechanical dissociation, Echocardiogram abnormal, Muscle contracture

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-25
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: 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
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.


Changed on 4/7/2010

VAERS ID: 289100 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:Illinois
Vaccinated:2007-08-23
Onset:2007-08-24
Submitted:2007-08-27
Entered:2007-08-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B115AA / 0 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 0 RL / IM
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B53981A / 0 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0508U / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Atrioventricular block complete, Blood culture, Bradycardia, Cerebellar hypoplasia, Chest X-ray normal, Cough, Death, Developmental delay, Diarrhoea, Failure to thrive, Feeding disorder neonatal, Hypertonia, Nuclear magnetic resonance imaging brain abnormal, Sneezing, Urinary system X-ray, Electromechanical dissociation, Echocardiogram abnormal, Muscle contracture

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-25
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: 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
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.


Changed on 8/31/2010

VAERS ID: 289100 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:Illinois
Vaccinated:2007-08-23
Onset:2007-08-24
Submitted:2007-08-27
Entered:2007-08-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B115AA / 0 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 0 RL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH B53981A / 0 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0508U / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Atrioventricular block complete, Blood culture, Bradycardia, Cerebellar hypoplasia, Chest X-ray normal, Cough, Death, Developmental delay, Diarrhoea, Failure to thrive, Feeding disorder neonatal, Hypertonia, Nuclear magnetic resonance imaging brain abnormal, Sneezing, Urinary system X-ray, Electromechanical dissociation, Echocardiogram abnormal, Muscle contracture

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-25
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: 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
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.


Changed on 4/13/2011

VAERS ID: 289100 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:Illinois
Vaccinated:2007-08-23
Onset:2007-08-24
Submitted:2007-08-27
Entered:2007-08-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B115AA / 0 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 0 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B53981A / 0 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0508U / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Atrioventricular block complete, Blood culture, Bradycardia, Cerebellar hypoplasia, Chest X-ray normal, Cough, Death, Developmental delay, Diarrhoea, Failure to thrive, Feeding disorder neonatal, Hypertonia, Nuclear magnetic resonance imaging brain abnormal, Sneezing, Urinary system X-ray, Electromechanical dissociation, Echocardiogram abnormal, Muscle contracture

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-25
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: 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
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.


Changed on 5/13/2011

VAERS ID: 289100 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:Illinois
Vaccinated:2007-08-23
Onset:2007-08-24
Submitted:2007-08-27
Entered:2007-08-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B115AA / 0 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 0 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B53981A / 0 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0508U / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Atrioventricular block complete, Blood culture, Bradycardia, Cerebellar hypoplasia, Chest X-ray normal, Cough, Death, Developmental delay, Diarrhoea, Failure to thrive, Feeding disorder neonatal, Hypertonia, Nuclear magnetic resonance imaging brain abnormal, Sneezing, Urinary system X-ray, Electromechanical dissociation, Echocardiogram abnormal, Muscle contracture

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-25
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: 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
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.


Changed on 6/11/2011

VAERS ID: 289100 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:Illinois
Vaccinated:2007-08-23
Onset:2007-08-24
Submitted:2007-08-27
Entered:2007-08-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B115AA / 0 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 0 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B53981A / 0 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0508U / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Atrioventricular block complete, Blood culture, Bradycardia, Cerebellar hypoplasia, Chest X-ray normal, Cough, Death, Developmental delay, Diarrhoea, Failure to thrive, Feeding disorder neonatal, Hypertonia, Nuclear magnetic resonance imaging brain abnormal, Sneezing, Urinary system X-ray, Electromechanical dissociation, Echocardiogram abnormal, Muscle contracture

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-25
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: 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
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.


Changed on 5/13/2013

VAERS ID: 289100 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:Illinois
Vaccinated:2007-08-23
Onset:2007-08-24
Submitted:2007-08-27
Entered:2007-08-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B115AA / 0 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 0 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B53981A / 0 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0508U / 0 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0508U / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Atrioventricular block complete, Blood culture, Bradycardia, Cerebellar hypoplasia, Chest X-ray normal, Cough, Death, Developmental delay, Diarrhoea, Failure to thrive, Feeding disorder neonatal, Hypertonia, Nuclear magnetic resonance imaging brain abnormal, Sneezing, Urinary system X-ray, Electromechanical dissociation, Echocardiogram abnormal, Muscle contracture

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-25
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: 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
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.


Changed on 5/14/2017

VAERS ID: 289100 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:Illinois
Vaccinated:2007-08-23
Onset:2007-08-24
Submitted:2007-08-27
Entered:2007-08-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B115AA / 0 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 0 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B53981A / 0 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0508U / 0 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Atrioventricular block complete, Blood culture, Bradycardia, Cerebellar hypoplasia, Chest X-ray normal, Cough, Death, Developmental delay, Diarrhoea, Failure to thrive, Feeding disorder neonatal, Hypertonia, Nuclear magnetic resonance imaging brain abnormal, Sneezing, Urinary system X-ray, Electromechanical dissociation, Echocardiogram abnormal, Muscle contracture

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-25
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: 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.


Changed on 9/14/2017

VAERS ID: 289100 Before After
VAERS Form:(blank) 1
Age:0.2
Sex:Male
Location:Illinois
Vaccinated:2007-08-23
Onset:2007-08-24
Submitted:2007-08-27
Entered:2007-08-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B115AA / 0 1 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 0 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B53981A / 0 1 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0508U / 0 1 - MO / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Death, Developmental delay, Failure to thrive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-25
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: 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.


Changed on 2/14/2018

VAERS ID: 289100 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Illinois
Vaccinated:2007-08-23
Onset:2007-08-24
Submitted:2007-08-27
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-25
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: 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.


Changed on 6/14/2018

VAERS ID: 289100 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Illinois
Vaccinated:2007-08-23
Onset:2007-08-24
Submitted:2007-08-27
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-25
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: 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.


Changed on 8/14/2018

VAERS ID: 289100 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Illinois
Vaccinated:2007-08-23
Onset:2007-08-24
Submitted:2007-08-27
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-25
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: 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.


Changed on 9/14/2018

VAERS ID: 289100 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Illinois
Vaccinated:2007-08-23
Onset:2007-08-24
Submitted:2007-08-27
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-25
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: 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.


Changed on 10/14/2018

VAERS ID: 289100 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Illinois
Vaccinated:2007-08-23
Onset:2007-08-24
Submitted:2007-08-27
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-25
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: 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.


Changed on 12/24/2020

VAERS ID: 289100 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Illinois
Vaccinated:2007-08-23
Onset:2007-08-24
Submitted:2007-08-27
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-25
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: 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.


Changed on 12/30/2020

VAERS ID: 289100 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Illinois
Vaccinated:2007-08-23
Onset:2007-08-24
Submitted:2007-08-27
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-25
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: 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.


Changed on 5/7/2021

VAERS ID: 289100 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Illinois
Vaccinated:2007-08-23
Onset:2007-08-24
Submitted:2007-08-27
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-25
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: 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.


Changed on 5/14/2021

VAERS ID: 289100 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Illinois
Vaccinated:2007-08-23
Onset:2007-08-24
Submitted:2007-08-27
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-25
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: 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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