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

This is VAERS ID 290566



Case Details

VAERS ID: 290566 (history)  
Form: Version 1.0  
Age: 0.4  
Sex: Female  
Location: California  
Vaccinated:2007-09-05
Onset:2007-09-05
   Days after vaccination:0
Submitted: 2007-09-12
   Days after onset:7
Entered: 2007-09-14
   Days after submission:2
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2650AA / 2 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR A0122 / 2 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0872 / 2 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B97283B / 2 LL / IM

Administered by: Private       Purchased by: Private
Symptoms: Autopsy, Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2007-09-05
   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:
Current Illness:
Preexisting Conditions: Reporter denied the patient had any illnesses, pre-existing medical conditions, use of other medications, or any adverse events following prior vaccinations at the time of the vaccinations on 05 September 2007. It was reported the patient had no known allergies. No vaccines were administered within four weeks prior to the vaccinations on 05 September 2007.
Allergies:
Diagnostic Lab Data:
CDC Split Type: 200703071

Write-up: Initial report received on 10 September 2007 from a health care professional. A four-month-old infant with no concurrent illnesses, no known allergies, and who had no pre-existing medical history, had received a second intramuscular dose of ActHib, lot number UF160AA (Sanofi Pasteur SA lot number A0122-2) in the left thigh; a second intramuscular dose of Daptacel, lot number C2650AA in the right thigh; a second intramuscular dose of IPOL, lot number Z0872-2 (reported as Z0872), in the right thigh; and a second intramuscular dose of Prevnar (manufacturer Wyeth), lot number B97283B, in the left thigh. The patient had not experienced any adverse events following prior vaccinations. Later that evening the patient was "found expired." Reportedly, an autopsy will be completed. 3/19/08 Reviewed autopsy report which states COD as complications of congenital pulmonary malformation. 3/19/08 Autopsy states pathologic diagnoses as: I. Congenital Pulmonary malformation with A. Microscopic characteristics most c/w congenital cystic adenomatoid malformation, Type I B. lymphocytic & macrophage peri-bronchial inflammation, mod to marked C. Intraalveolar hemorrhage, marked D. pulmonary edema, marked III. Abnormal 17 hydroxyprogesterone study w/o microscopic abnormality of adrenal glands.


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