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This is VAERS ID 337243

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History of Changes from the VAERS Wayback Machine

First Appeared on 12/8/2009

VAERS ID: 337243
VAERS Form:
Age:0.4
Sex:Male
Location:Pennsylvania
Vaccinated:2008-12-11
Onset:2008-12-16
Submitted:2009-01-09
Entered:2009-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2957AA / 1 UN / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF4U5AA / 1 UN / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 1 UN / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC D01074 / 1 UN / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0217X / 1 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, Blood chloride increased, Blood culture negative, Blood fibrinogen decreased, Blood glucose decreased, Blood lactic acid increased, Blood potassium increased, Chest X-ray abnormal, Computerised tomogram abnormal, Convulsion, CSF culture negative, CSF protein increased, Culture urine negative, Death, Diarrhoea, Electroencephalogram abnormal, Electrolyte imbalance, Encephalopathy, Eye rolling, Fibrin D dimer increased, Full blood count, Haemoglobin decreased, Hyperhidrosis, Hypoglycaemia, International normalised ratio increased, Livedo reticularis, Liver function test abnormal, Metabolic acidosis, Multi-organ failure, Peripheral coldness, Platelet count decreased, Prothrombin time prolonged, Status epilepticus, Unresponsive to stimuli, White blood cell count increased, Shock haemorrhagic, CSF glucose increased, Respiratory tract congestion, Scan brain, Lymphocyte morphology abnormal, Rotavirus test positive, Coagulation test abnormal, Carbon dioxide abnormal, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-18
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: Tylenol
Current Illness: None
Preexisting Conditions: None. PMH: none.
Allergies:
Diagnostic Lab Data: See attached. Labs and Diagnostics: CBC with 43K WBCs with 20% atypical lymphs. CT brain scan (+) cerebral edema and probable ischemic infarcts. CSF (+) for few PMNs, CSF glucose 105, CSF protein 62. CSF cx (-). EEG abnormal. Rotavirus
CDC 'Split Type':

Write-up: Patient developed hemorrhagic shock w/ encephalopathy syndrome 5 days after vaccine administration and died. 1/27/2009 MR received for DOS 12/16-18/2008 which was the Date of death. Principal DX: Multisystem organ failure 2'' to Hemorrhagic Shock and Encephalopathy Syndrome (HSES). Pt initially presented with new onset seizures and diarrhea. Pt in usual state of good health a.m. of 1/16/09 except for some recent mild congestion. Later noted to be sweaty and did not respond while parent was changing clothes. Later noted to be eye rolling and making unusual movements. In status epilepticus and metabolic acidosis on arrivial in local ED. Intubated and medicated for seizures and transferred to higher level of care. Cool and mottled on arrival. LFTs elevated. Issues with hypoglycemia, abnormal coags and electrolyte fluctuations with little response to tx. Parents elected to withdraw life support follwing notification of fatal status of illness. 2/12/09 Death Cert received. COD- Multiorgan Failure. Hemorrhagic Shock and Encephalopathy Syndrome.


Changed on 3/2/2010

VAERS ID: 337243 Before After
VAERS Form:
Age:0.4
Sex:Male
Location:Pennsylvania
Vaccinated:2008-12-11
Onset:2008-12-16
Submitted:2009-01-09
Entered:2009-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2957AA / 1 UN / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF4U5AA / 1 UN / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 1 UN / IM
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC D01074 / 1 UN / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0217X / 1 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, Blood chloride increased, Blood culture negative, Blood fibrinogen decreased, Blood glucose decreased, Blood lactic acid increased, Blood potassium increased, Chest X-ray abnormal, Computerised tomogram abnormal, Convulsion, CSF culture negative, CSF protein increased, Culture urine negative, Death, Diarrhoea, Electroencephalogram abnormal, Electrolyte imbalance, Encephalopathy, Eye rolling, Fibrin D dimer increased, Full blood count, Haemoglobin decreased, Hyperhidrosis, Hypoglycaemia, International normalised ratio increased, Livedo reticularis, Liver function test abnormal, Metabolic acidosis, Multi-organ failure, Peripheral coldness, Platelet count decreased, Prothrombin time prolonged, Status epilepticus, Unresponsive to stimuli, White blood cell count increased, Shock haemorrhagic, CSF glucose increased, Respiratory tract congestion, Scan brain, Lymphocyte morphology abnormal, Rotavirus test positive, Coagulation test abnormal, Carbon dioxide abnormal, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-18
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: Tylenol
Current Illness: None
Preexisting Conditions: None. PMH: none.
Allergies:
Diagnostic Lab Data: See attached. Labs and Diagnostics: CBC with 43K WBCs with 20% atypical lymphs. CT brain scan (+) cerebral edema and probable ischemic infarcts. CSF (+) for few PMNs, CSF glucose 105, CSF protein 62. CSF cx (-). EEG abnormal. Rotavirus
CDC 'Split Type':

Write-up: Patient developed hemorrhagic shock w/ encephalopathy syndrome 5 days after vaccine administration and died. 1/27/2009 MR received for DOS 12/16-18/2008 which was the Date of death. Principal DX: Multisystem organ failure 2'' to Hemorrhagic Shock and Encephalopathy Syndrome (HSES). Pt initially presented with new onset seizures and diarrhea. Pt in usual state of good health a.m. of 1/16/09 except for some recent mild congestion. Later noted to be sweaty and did not respond while parent was changing clothes. Later noted to be eye rolling and making unusual movements. In status epilepticus and metabolic acidosis on arrivial in local ED. Intubated and medicated for seizures and transferred to higher level of care. Cool and mottled on arrival. LFTs elevated. Issues with hypoglycemia, abnormal coags and electrolyte fluctuations with little response to tx. Parents elected to withdraw life support follwing notification of fatal status of illness. 2/12/09 Death Cert received. COD- Multiorgan Failure. Hemorrhagic Shock and Encephalopathy Syndrome.


Changed on 4/7/2010

VAERS ID: 337243 Before After
VAERS Form:
Age:0.4
Sex:Male
Location:Pennsylvania
Vaccinated:2008-12-11
Onset:2008-12-16
Submitted:2009-01-09
Entered:2009-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2957AA / 1 UN / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF4U5AA / 1 UN / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 1 UN / IM
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC D01074 / 1 UN / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0217X / 1 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, Blood chloride increased, Blood culture negative, Blood fibrinogen decreased, Blood glucose decreased, Blood lactic acid increased, Blood potassium increased, Chest X-ray abnormal, Computerised tomogram abnormal, Convulsion, CSF culture negative, CSF protein increased, Culture urine negative, Death, Diarrhoea, Electroencephalogram abnormal, Electrolyte imbalance, Encephalopathy, Eye rolling, Fibrin D dimer increased, Full blood count, Haemoglobin decreased, Hyperhidrosis, Hypoglycaemia, International normalised ratio increased, Livedo reticularis, Liver function test abnormal, Metabolic acidosis, Multi-organ failure, Peripheral coldness, Platelet count decreased, Prothrombin time prolonged, Status epilepticus, Unresponsive to stimuli, White blood cell count increased, Shock haemorrhagic, CSF glucose increased, Respiratory tract congestion, Scan brain, Lymphocyte morphology abnormal, Rotavirus test positive, Coagulation test abnormal, Carbon dioxide abnormal, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-18
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: Tylenol
Current Illness: None
Preexisting Conditions: None. PMH: none.
Allergies:
Diagnostic Lab Data: See attached. Labs and Diagnostics: CBC with 43K WBCs with 20% atypical lymphs. CT brain scan (+) cerebral edema and probable ischemic infarcts. CSF (+) for few PMNs, CSF glucose 105, CSF protein 62. CSF cx (-). EEG abnormal. Rotavirus
CDC 'Split Type':

Write-up: Patient developed hemorrhagic shock w/ encephalopathy syndrome 5 days after vaccine administration and died. 1/27/2009 MR received for DOS 12/16-18/2008 which was the Date of death. Principal DX: Multisystem organ failure 2'' to Hemorrhagic Shock and Encephalopathy Syndrome (HSES). Pt initially presented with new onset seizures and diarrhea. Pt in usual state of good health a.m. of 1/16/09 except for some recent mild congestion. Later noted to be sweaty and did not respond while parent was changing clothes. Later noted to be eye rolling and making unusual movements. In status epilepticus and metabolic acidosis on arrivial in local ED. Intubated and medicated for seizures and transferred to higher level of care. Cool and mottled on arrival. LFTs elevated. Issues with hypoglycemia, abnormal coags and electrolyte fluctuations with little response to tx. Parents elected to withdraw life support follwing notification of fatal status of illness. 2/12/09 Death Cert received. COD- Multiorgan Failure. Hemorrhagic Shock and Encephalopathy Syndrome.


Changed on 8/31/2010

VAERS ID: 337243 Before After
VAERS Form:
Age:0.4
Sex:Male
Location:Pennsylvania
Vaccinated:2008-12-11
Onset:2008-12-16
Submitted:2009-01-09
Entered:2009-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2957AA / 1 UN / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF4U5AA / 1 UN / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 1 UN / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH D01074 / 1 UN / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0217X / 1 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, Blood chloride increased, Blood culture negative, Blood fibrinogen decreased, Blood glucose decreased, Blood lactic acid increased, Blood potassium increased, Chest X-ray abnormal, Computerised tomogram abnormal, Convulsion, CSF culture negative, CSF protein increased, Culture urine negative, Death, Diarrhoea, Electroencephalogram abnormal, Electrolyte imbalance, Encephalopathy, Eye rolling, Fibrin D dimer increased, Full blood count, Haemoglobin decreased, Hyperhidrosis, Hypoglycaemia, International normalised ratio increased, Livedo reticularis, Liver function test abnormal, Metabolic acidosis, Multi-organ failure, Peripheral coldness, Platelet count decreased, Prothrombin time prolonged, Status epilepticus, Unresponsive to stimuli, White blood cell count increased, Shock haemorrhagic, CSF glucose increased, Respiratory tract congestion, Scan brain, Lymphocyte morphology abnormal, Rotavirus test positive, Coagulation test abnormal, Carbon dioxide abnormal, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-18
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: Tylenol
Current Illness: None
Preexisting Conditions: None. PMH: none.
Allergies:
Diagnostic Lab Data: See attached. Labs and Diagnostics: CBC with 43K WBCs with 20% atypical lymphs. CT brain scan (+) cerebral edema and probable ischemic infarcts. CSF (+) for few PMNs, CSF glucose 105, CSF protein 62. CSF cx (-). EEG abnormal. Rotavirus
CDC 'Split Type':

Write-up: Patient developed hemorrhagic shock w/ encephalopathy syndrome 5 days after vaccine administration and died. 1/27/2009 MR received for DOS 12/16-18/2008 which was the Date of death. Principal DX: Multisystem organ failure 2'' to Hemorrhagic Shock and Encephalopathy Syndrome (HSES). Pt initially presented with new onset seizures and diarrhea. Pt in usual state of good health a.m. of 1/16/09 except for some recent mild congestion. Later noted to be sweaty and did not respond while parent was changing clothes. Later noted to be eye rolling and making unusual movements. In status epilepticus and metabolic acidosis on arrivial in local ED. Intubated and medicated for seizures and transferred to higher level of care. Cool and mottled on arrival. LFTs elevated. Issues with hypoglycemia, abnormal coags and electrolyte fluctuations with little response to tx. Parents elected to withdraw life support follwing notification of fatal status of illness. 2/12/09 Death Cert received. COD- Multiorgan Failure. Hemorrhagic Shock and Encephalopathy Syndrome.


Changed on 2/13/2013

VAERS ID: 337243 Before After
VAERS Form:
Age:0.4
Sex:Male
Location:Pennsylvania
Vaccinated:2008-12-11
Onset:2008-12-16
Submitted:2009-01-09
Entered:2009-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2957AA / 1 UN / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF4U5AA / 1 UN / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 1 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH D01074 / 1 UN / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0217X / 1 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, Blood chloride increased, Blood culture negative, Blood fibrinogen decreased, Blood glucose decreased, Blood lactic acid increased, Blood potassium increased, Chest X-ray abnormal, Computerised tomogram abnormal, Convulsion, CSF culture negative, CSF protein increased, Culture urine negative, Death, Diarrhoea, Electroencephalogram abnormal, Electrolyte imbalance, Encephalopathy, Eye rolling, Fibrin D dimer increased, Full blood count, Haemoglobin decreased, Hyperhidrosis, Hypoglycaemia, International normalised ratio increased, Livedo reticularis, Liver function test abnormal, Metabolic acidosis, Multi-organ failure, Peripheral coldness, Platelet count decreased, Prothrombin time prolonged, Status epilepticus, Unresponsive to stimuli, White blood cell count increased, Shock haemorrhagic, CSF glucose increased, Respiratory tract congestion, Scan brain, Lymphocyte morphology abnormal, Rotavirus test positive, Coagulation test abnormal, Carbon dioxide abnormal, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-18
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: Tylenol
Current Illness: None
Preexisting Conditions: None. PMH: none.
Allergies:
Diagnostic Lab Data: See attached. Labs and Diagnostics: CBC with 43K WBCs with 20% atypical lymphs. CT brain scan (+) cerebral edema and probable ischemic infarcts. CSF (+) for few PMNs, CSF glucose 105, CSF protein 62. CSF cx (-). EEG abnormal. Rotavirus (+), likely due to shedding. ALT 938-9,480. AST 1,974-12,822. Blood cx (-). UC (-). Hgb 9.2. Platelets WNL on admission down to 105K. Lactate 5.3 on adm up to 10.2. PT 36.3-49.5. INR 3.54-5.22. PTT 42-56. Fibrinogen dropped from 153-137. D-dimer $g 20. CXR (+) for atelectasis. K+ 6.1. CO2 12. Cl- 110. Glucose 55.
CDC 'Split Type':

Write-up: Patient developed hemorrhagic shock w/ encephalopathy syndrome 5 days after vaccine administration and died. 1/27/2009 MR received for DOS 12/16-18/2008 which was the Date of death. Principal DX: Multisystem organ failure 2'' to Hemorrhagic Shock and Encephalopathy Syndrome (HSES). Pt initially presented with new onset seizures and diarrhea. Pt in usual state of good health a.m. of 1/16/09 except for some recent mild congestion. Later noted to be sweaty and did not respond while parent was changing clothes. Later noted to be eye rolling and making unusual movements. In status epilepticus and metabolic acidosis on arrivial in local ED. Intubated and medicated for seizures and transferred to higher level of care. Cool and mottled on arrival. LFTs elevated. Issues with hypoglycemia, abnormal coags and electrolyte fluctuations with little response to tx. Parents elected to withdraw life support follwing notification of fatal status of illness. 2/12/09 Death Cert received. COD- Multiorgan Failure. Hemorrhagic Shock and Encephalopathy Syndrome.


Changed on 5/13/2013

VAERS ID: 337243 Before After
VAERS Form:
Age:0.4
Sex:Male
Location:Pennsylvania
Vaccinated:2008-12-11
Onset:2008-12-16
Submitted:2009-01-09
Entered:2009-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2957AA / 1 UN / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF4U5AA / 1 UN / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 1 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH D01074 / 1 UN / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0217X / 1 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0217X / 1 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, Blood chloride increased, Blood culture negative, Blood fibrinogen decreased, Blood glucose decreased, Blood lactic acid increased, Blood potassium increased, Chest X-ray abnormal, Computerised tomogram abnormal, Convulsion, CSF culture negative, CSF protein increased, Culture urine negative, Death, Diarrhoea, Electroencephalogram abnormal, Electrolyte imbalance, Encephalopathy, Eye rolling, Fibrin D dimer increased, Full blood count, Haemoglobin decreased, Hyperhidrosis, Hypoglycaemia, International normalised ratio increased, Livedo reticularis, Liver function test abnormal, Metabolic acidosis, Multi-organ failure, Peripheral coldness, Platelet count decreased, Prothrombin time prolonged, Status epilepticus, Unresponsive to stimuli, White blood cell count increased, Shock haemorrhagic, CSF glucose increased, Respiratory tract congestion, Scan brain, Lymphocyte morphology abnormal, Rotavirus test positive, Coagulation test abnormal, Carbon dioxide abnormal, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-18
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: Tylenol
Current Illness: None
Preexisting Conditions: None. PMH: none.
Allergies:
Diagnostic Lab Data: See attached. Labs and Diagnostics: CBC with 43K WBCs with 20% atypical lymphs. CT brain scan (+) cerebral edema and probable ischemic infarcts. CSF (+) for few PMNs, CSF glucose 105, CSF protein 62. CSF cx (-). EEG abnormal. Rotavirus (+), likely due to shedding. ALT 938-9,480. AST 1,974-12,822. Blood cx (-). UC (-). Hgb 9.2. Platelets WNL on admission down to 105K. Lactate 5.3 on adm up to 10.2. PT 36.3-49.5. INR 3.54-5.22. PTT 42-56. Fibrinogen dropped from 153-137. D-dimer $g 20. CXR (+) for atelectasis. K+ 6.1. CO2 12. Cl- 110. Glucose 55.
CDC 'Split Type':

Write-up: Patient developed hemorrhagic shock w/ encephalopathy syndrome 5 days after vaccine administration and died. 1/27/2009 MR received for DOS 12/16-18/2008 which was the Date of death. Principal DX: Multisystem organ failure 2'' to Hemorrhagic Shock and Encephalopathy Syndrome (HSES). Pt initially presented with new onset seizures and diarrhea. Pt in usual state of good health a.m. of 1/16/09 except for some recent mild congestion. Later noted to be sweaty and did not respond while parent was changing clothes. Later noted to be eye rolling and making unusual movements. In status epilepticus and metabolic acidosis on arrivial in local ED. Intubated and medicated for seizures and transferred to higher level of care. Cool and mottled on arrival. LFTs elevated. Issues with hypoglycemia, abnormal coags and electrolyte fluctuations with little response to tx. Parents elected to withdraw life support follwing notification of fatal status of illness. 2/12/09 Death Cert received. COD- Multiorgan Failure. Hemorrhagic Shock and Encephalopathy Syndrome.


Changed on 6/14/2014

VAERS ID: 337243 Before After
VAERS Form:
Age:0.4
Sex:Male
Location:Pennsylvania
Vaccinated:2008-12-11
Onset:2008-12-16
Submitted:2009-01-09
Entered:2009-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2957AA / 1 UN / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF4U5AA / 1 UN / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 1 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH D01074 / 1 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0217X / 1 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, Blood chloride increased, Blood culture negative, Blood fibrinogen decreased, Blood glucose decreased, Blood lactic acid increased, Blood potassium increased, Chest X-ray abnormal, Computerised tomogram abnormal, Convulsion, CSF culture negative, CSF protein increased, Culture urine negative, Death, Diarrhoea, Electroencephalogram abnormal, Electrolyte imbalance, Encephalopathy, Eye rolling, Fibrin D dimer increased, Full blood count, Haemoglobin decreased, Hyperhidrosis, Hypoglycaemia, International normalised ratio increased, Livedo reticularis, Liver function test abnormal, Metabolic acidosis, Multi-organ failure, Peripheral coldness, Platelet count decreased, Prothrombin time prolonged, Status epilepticus, Unresponsive to stimuli, White blood cell count increased, Shock haemorrhagic, CSF glucose increased, Respiratory tract congestion, Scan brain, Lymphocyte morphology abnormal, Rotavirus test positive, Coagulation test abnormal, Carbon dioxide abnormal, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-18
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: Tylenol
Current Illness: None
Preexisting Conditions: None. PMH: none.
Allergies:
Diagnostic Lab Data: See attached. Labs and Diagnostics: CBC with 43K WBCs with 20% atypical lymphs. CT brain scan (+) cerebral edema and probable ischemic infarcts. CSF (+) for few PMNs, CSF glucose 105, CSF protein 62. CSF cx (-). EEG abnormal. Rotavirus (+), likely due to shedding. ALT 938-9,480. AST 1,974-12,822. Blood cx (-). UC (-). Hgb 9.2. Platelets WNL on admission down to 105K. Lactate 5.3 on adm up to 10.2. PT 36.3-49.5. INR 3.54-5.22. PTT 42-56. Fibrinogen dropped from 153-137. D-dimer $g 20. CXR (+) for atelectasis. K+ 6.1. CO2 12. Cl- 110. Glucose 55.
CDC 'Split Type':

Write-up: Patient developed hemorrhagic shock w/ encephalopathy syndrome 5 days after vaccine administration and died. 1/27/2009 MR received for DOS 12/16-18/2008 which was the Date of death. Principal DX: Multisystem organ failure 2'' to Hemorrhagic Shock and Encephalopathy Syndrome (HSES). Pt initially presented with new onset seizures and diarrhea. Pt in usual state of good health a.m. of 1/16/09 except for some recent mild congestion. Later noted to be sweaty and did not respond while parent was changing clothes. Later noted to be eye rolling and making unusual movements. In status epilepticus and metabolic acidosis on arrivial in local ED. Intubated and medicated for seizures and transferred to higher level of care. Cool and mottled on arrival. LFTs elevated. Issues with hypoglycemia, abnormal coags and electrolyte fluctuations with little response to tx. Parents elected to withdraw life support follwing notification of fatal status of illness. 2/12/09 Death Cert received. COD- Multiorgan Failure. Hemorrhagic Shock and Encephalopathy Syndrome.


Changed on 3/14/2015

VAERS ID: 337243 Before After
VAERS Form:
Age:0.4
Sex:Male
Location:Pennsylvania
Vaccinated:2008-12-11
Onset:2008-12-16
Submitted:2009-01-09
Entered:2009-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2957AA / 1 UN / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF4U5AA / 1 UN / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 1 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH D01074 / 1 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0217X / 1 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, Blood chloride increased, Blood culture negative, Blood fibrinogen decreased, Blood glucose decreased, Blood lactic acid increased, Blood potassium increased, Chest X-ray abnormal, Computerised tomogram abnormal, Convulsion, CSF culture negative, CSF protein increased, Culture urine negative, Death, Diarrhoea, Electroencephalogram abnormal, Electrolyte imbalance, Encephalopathy, Eye rolling, Fibrin D dimer increased, Full blood count, Haemoglobin decreased, Hyperhidrosis, Hypoglycaemia, International normalised ratio increased, Livedo reticularis, Liver function test abnormal, Metabolic acidosis, Multi-organ failure, Peripheral coldness, Platelet count decreased, Prothrombin time prolonged, Status epilepticus, Unresponsive to stimuli, White blood cell count increased, Shock haemorrhagic, CSF glucose increased, Respiratory tract congestion, Scan brain, Lymphocyte morphology abnormal, Rotavirus test positive, Coagulation test abnormal, Carbon dioxide abnormal, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-18
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: Tylenol
Current Illness: None
Preexisting Conditions: None. PMH: none.
Allergies:
Diagnostic Lab Data: See attached. Labs and Diagnostics: CBC with 43K WBCs with 20% atypical lymphs. CT brain scan (+) cerebral edema and probable ischemic infarcts. CSF (+) for few PMNs, CSF glucose 105, CSF protein 62. CSF cx (-). EEG abnormal. Rotavirus (+), likely due to shedding. ALT 938-9,480. AST 1,974-12,822. Blood cx (-). UC (-). Hgb 9.2. Platelets WNL on admission down to 105K. Lactate 5.3 on adm up to 10.2. PT 36.3-49.5. INR 3.54-5.22. PTT 42-56. Fibrinogen dropped from 153-137. D-dimer $g 20. CXR (+) for atelectasis. K+ 6.1. CO2 12. Cl- 110. Glucose 55.
CDC 'Split Type':

Write-up: Patient developed hemorrhagic shock w/ encephalopathy syndrome 5 days after vaccine administration and died. 1/27/2009 MR received for DOS 12/16-18/2008 which was the Date of death. Principal DX: Multisystem organ failure 2'' to Hemorrhagic Shock and Encephalopathy Syndrome (HSES). Pt initially presented with new onset seizures and diarrhea. Pt in usual state of good health a.m. of 1/16/09 except for some recent mild congestion. Later noted to be sweaty and did not respond while parent was changing clothes. Later noted to be eye rolling and making unusual movements. In status epilepticus and metabolic acidosis on arrivial in local ED. Intubated and medicated for seizures and transferred to higher level of care. Cool and mottled on arrival. LFTs elevated. Issues with hypoglycemia, abnormal coags and electrolyte fluctuations with little response to tx. Parents elected to withdraw life support follwing notification of fatal status of illness. 2/12/09 Death Cert received. COD- Multiorgan Failure. Hemorrhagic Shock and Encephalopathy Syndrome.


Changed on 2/14/2017

VAERS ID: 337243 Before After
VAERS Form:
Age:0.4 0.44
Sex:Male
Location:Pennsylvania
Vaccinated:2008-12-11
Onset:2008-12-16
Submitted:2009-01-09
Entered:2009-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2957AA / 1 UN / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF4U5AA / 1 UN / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 1 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH D01074 / 1 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0217X / 1 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, Blood chloride increased, Blood culture negative, Blood fibrinogen decreased, Blood glucose decreased, Blood lactic acid increased, Blood potassium increased, Chest X-ray abnormal, Computerised tomogram abnormal, Convulsion, CSF culture negative, CSF protein increased, Culture urine negative, Death, Diarrhoea, Electroencephalogram abnormal, Electrolyte imbalance, Encephalopathy, Eye rolling, Fibrin D dimer increased, Full blood count, Haemoglobin decreased, Hyperhidrosis, Hypoglycaemia, International normalised ratio increased, Livedo reticularis, Liver function test abnormal, Metabolic acidosis, Multi-organ failure, Peripheral coldness, Platelet count decreased, Prothrombin time prolonged, Status epilepticus, Unresponsive to stimuli, White blood cell count increased, Shock haemorrhagic, CSF glucose increased, Respiratory tract congestion, Scan brain, Lymphocyte morphology abnormal, Rotavirus test positive, Coagulation test abnormal, Carbon dioxide abnormal, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-18
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: Tylenol
Current Illness: None
Preexisting Conditions: None. PMH: none.
Allergies:
Diagnostic Lab Data: See attached. Labs and Diagnostics: CBC with 43K WBCs with 20% atypical lymphs. CT brain scan (+) cerebral edema and probable ischemic infarcts. CSF (+) for few PMNs, CSF glucose 105, CSF protein 62. CSF cx (-). EEG abnormal. Rotavirus (+), likely due to shedding. ALT 938-9,480. AST 1,974-12,822. Blood cx (-). UC (-). Hgb 9.2. Platelets WNL on admission down to 105K. Lactate 5.3 on adm up to 10.2. PT 36.3-49.5. INR 3.54-5.22. PTT 42-56. Fibrinogen dropped from 153-137. D-dimer $g 20. CXR (+) for atelectasis. K+ 6.1. CO2 12. Cl- 110. Glucose 55.
CDC 'Split Type':

Write-up: Patient developed hemorrhagic shock w/ encephalopathy syndrome 5 days after vaccine administration and died. 1/27/2009 MR received for DOS 12/16-18/2008 which was the Date of death. Principal DX: Multisystem organ failure 2'' to Hemorrhagic Shock and Encephalopathy Syndrome (HSES). Pt initially presented with new onset seizures and diarrhea. Pt in usual state of good health a.m. of 1/16/09 except for some recent mild congestion. Later noted to be sweaty and did not respond while parent was changing clothes. Later noted to be eye rolling and making unusual movements. In status epilepticus and metabolic acidosis on arrivial in local ED. Intubated and medicated for seizures and transferred to higher level of care. Cool and mottled on arrival. LFTs elevated. Issues with hypoglycemia, abnormal coags and electrolyte fluctuations with little response to tx. Parents elected to withdraw life support follwing notification of fatal status of illness. 2/12/09 Death Cert received. COD- Multiorgan Failure. Hemorrhagic Shock and Encephalopathy Syndrome.


Changed on 4/14/2017

VAERS ID: 337243 Before After
VAERS Form:
Age:0.44
Sex:Male
Location:Pennsylvania
Vaccinated:2008-12-11
Onset:2008-12-16
Submitted:2009-01-09
Entered:2009-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2957AA / 1 UN / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF4U5AA / 1 UN / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 1 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH D01074 / 1 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0217X / 1 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, Blood chloride increased, Blood culture negative, Blood fibrinogen decreased, Blood glucose decreased, Blood lactic acid increased, Blood potassium increased, Chest X-ray abnormal, Computerised tomogram abnormal, Convulsion, CSF culture negative, CSF protein increased, Culture urine negative, Death, Diarrhoea, Electroencephalogram abnormal, Electrolyte imbalance, Encephalopathy, Eye rolling, Fibrin D dimer increased, Full blood count, Haemoglobin decreased, Hyperhidrosis, Hypoglycaemia, International normalised ratio increased, Livedo reticularis, Liver function test abnormal, Metabolic acidosis, Multi-organ failure, Peripheral coldness, Platelet count decreased, Prothrombin time prolonged, Status epilepticus, Unresponsive to stimuli, White blood cell count increased, Shock haemorrhagic, CSF glucose increased, Respiratory tract congestion, Scan brain, Lymphocyte morphology abnormal, Rotavirus test positive, Coagulation test abnormal, Carbon dioxide abnormal, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-18
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: Tylenol
Current Illness: None
Preexisting Conditions: None. PMH: none.
Allergies:
Diagnostic Lab Data: See attached. Labs and Diagnostics: CBC with 43K WBCs with 20% atypical lymphs. CT brain scan (+) cerebral edema and probable ischemic infarcts. CSF (+) for few PMNs, CSF glucose 105, CSF protein 62. CSF cx (-). EEG abnormal. Rotavirus (+), likely due to shedding. ALT 938-9,480. AST 1,974-12,822. Blood cx (-). UC (-). Hgb 9.2. Platelets WNL on admission down to 105K. Lactate 5.3 on adm up to 10.2. PT 36.3-49.5. INR 3.54-5.22. PTT 42-56. Fibrinogen dropped from 153-137. D-dimer $g 20. CXR (+) for atelectasis. K+ 6.1. CO2 12. Cl- 110. Glucose 55.
CDC 'Split Type':

Write-up: Patient developed hemorrhagic shock w/ encephalopathy syndrome 5 days after vaccine administration and died. 1/27/2009 MR received for DOS 12/16-18/2008 which was the Date of death. Principal DX: Multisystem organ failure 2'' to Hemorrhagic Shock and Encephalopathy Syndrome (HSES). Pt initially presented with new onset seizures and diarrhea. Pt in usual state of good health a.m. of 1/16/09 except for some recent mild congestion. Later noted to be sweaty and did not respond while parent was changing clothes. Later noted to be eye rolling and making unusual movements. In status epilepticus and metabolic acidosis on arrivial in local ED. Intubated and medicated for seizures and transferred to higher level of care. Cool and mottled on arrival. LFTs elevated. Issues with hypoglycemia, abnormal coags and electrolyte fluctuations with little response to tx. Parents elected to withdraw life support follwing notification of fatal status of illness. 2/12/09 Death Cert received. COD- Multiorgan Failure. Hemorrhagic Shock and Encephalopathy Syndrome.


Changed on 9/14/2017

VAERS ID: 337243 Before After
VAERS Form:(blank) 1
Age:0.44
Sex:Male
Location:Pennsylvania
Vaccinated:2008-12-11
Onset:2008-12-16
Submitted:2009-01-09
Entered:2009-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2957AA / 1 2 UN / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF4U5AA / 1 2 UN / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 1 2 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH D01074 / 1 2 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0217X / 1 2 - MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Death, Encephalopathy, Shock haemorrhagic

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-18
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: Tylenol
Current Illness: None
Preexisting Conditions: None. PMH: none.
Allergies:
Diagnostic Lab Data: See attached. Labs and Diagnostics: CBC with 43K WBCs with 20% atypical lymphs. CT brain scan (+) cerebral edema and probable ischemic infarcts. CSF (+) for few PMNs, CSF glucose 105, CSF protein 62. CSF cx (-). EEG abnormal. Rotavirus (+), likely due to shedding. ALT 938-9,480. AST 1,974-12,822. Blood cx (-). UC (-). Hgb 9.2. Platelets WNL on admission down to 105K. Lactate 5.3 on adm up to 10.2. PT 36.3-49.5. INR 3.54-5.22. PTT 42-56. Fibrinogen dropped from 153-137. D-dimer $g 20. CXR (+) for atelectasis. K+ 6.1. CO2 12. Cl- 110. Glucose 55.
CDC 'Split Type':

Write-up: Patient developed hemorrhagic shock w/ encephalopathy syndrome 5 days after vaccine administration and died. 1/27/2009 MR received for DOS 12/16-18/2008 which was the Date of death. Principal DX: Multisystem organ failure 2'' to Hemorrhagic Shock and Encephalopathy Syndrome (HSES). Pt initially presented with new onset seizures and diarrhea. Pt in usual state of good health a.m. of 1/16/09 except for some recent mild congestion. Later noted to be sweaty and did not respond while parent was changing clothes. Later noted to be eye rolling and making unusual movements. In status epilepticus and metabolic acidosis on arrivial in local ED. Intubated and medicated for seizures and transferred to higher level of care. Cool and mottled on arrival. LFTs elevated. Issues with hypoglycemia, abnormal coags and electrolyte fluctuations with little response to tx. Parents elected to withdraw life support follwing notification of fatal status of illness. 2/12/09 Death Cert received. COD- Multiorgan Failure. Hemorrhagic Shock and Encephalopathy Syndrome.


Changed on 2/14/2018

VAERS ID: 337243 Before After
VAERS Form:1
Age:0.44
Sex:Male
Location:Pennsylvania
Vaccinated:2008-12-11
Onset:2008-12-16
Submitted:2009-01-09
Entered:2009-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2957AA / 2 UN / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF4U5AA / 2 UN / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 2 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH D01074 / 2 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0217X / 2 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Death, Encephalopathy, Shock haemorrhagic

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-18
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: Tylenol
Current Illness: None
Preexisting Conditions: None. PMH: none.
Allergies:
Diagnostic Lab Data: See attached. Labs and Diagnostics: CBC with 43K WBCs with 20% atypical lymphs. CT brain scan (+) cerebral edema and probable ischemic infarcts. CSF (+) for few PMNs, CSF glucose 105, CSF protein 62. CSF cx (-). EEG abnormal. Rotavirus (+), likely due to shedding. ALT 938-9,480. AST 1,974-12,822. Blood cx (-). UC (-). Hgb 9.2. Platelets WNL on admission down to 105K. Lactate 5.3 on adm up to 10.2. PT 36.3-49.5. INR 3.54-5.22. PTT 42-56. Fibrinogen dropped from 153-137. D-dimer $g 20. CXR (+) for atelectasis. K+ 6.1. CO2 12. Cl- 110. Glucose 55.
CDC 'Split Type':

Write-up: Patient developed hemorrhagic shock w/ encephalopathy syndrome 5 days after vaccine administration and died. 1/27/2009 MR received for DOS 12/16-18/2008 which was the Date of death. Principal DX: Multisystem organ failure 2'' to Hemorrhagic Shock and Encephalopathy Syndrome (HSES). Pt initially presented with new onset seizures and diarrhea. Pt in usual state of good health a.m. of 1/16/09 except for some recent mild congestion. Later noted to be sweaty and did not respond while parent was changing clothes. Later noted to be eye rolling and making unusual movements. In status epilepticus and metabolic acidosis on arrivial in local ED. Intubated and medicated for seizures and transferred to higher level of care. Cool and mottled on arrival. LFTs elevated. Issues with hypoglycemia, abnormal coags and electrolyte fluctuations with little response to tx. Parents elected to withdraw life support follwing notification of fatal status of illness. 2/12/09 Death Cert received. COD- Multiorgan Failure. Hemorrhagic Shock and Encephalopathy Syndrome.


Changed on 6/14/2018

VAERS ID: 337243 Before After
VAERS Form:1
Age:0.44
Sex:Male
Location:Pennsylvania
Vaccinated:2008-12-11
Onset:2008-12-16
Submitted:2009-01-09
Entered:2009-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2957AA / 2 UN / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF4U5AA / 2 UN / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 2 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH D01074 / 2 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0217X / 2 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Death, Encephalopathy, Shock haemorrhagic

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-18
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: Tylenol
Current Illness: None
Preexisting Conditions: None. PMH: none.
Allergies:
Diagnostic Lab Data: See attached. Labs and Diagnostics: CBC with 43K WBCs with 20% atypical lymphs. CT brain scan (+) cerebral edema and probable ischemic infarcts. CSF (+) for few PMNs, CSF glucose 105, CSF protein 62. CSF cx (-). EEG abnormal. Rotavirus (+), likely due to shedding. ALT 938-9,480. AST 1,974-12,822. Blood cx (-). UC (-). Hgb 9.2. Platelets WNL on admission down to 105K. Lactate 5.3 on adm up to 10.2. PT 36.3-49.5. INR 3.54-5.22. PTT 42-56. Fibrinogen dropped from 153-137. D-dimer $g 20. CXR (+) for atelectasis. K+ 6.1. CO2 12. Cl- 110. Glucose 55.
CDC 'Split Type':

Write-up: Patient developed hemorrhagic shock w/ encephalopathy syndrome 5 days after vaccine administration and died. 1/27/2009 MR received for DOS 12/16-18/2008 which was the Date of death. Principal DX: Multisystem organ failure 2'' to Hemorrhagic Shock and Encephalopathy Syndrome (HSES). Pt initially presented with new onset seizures and diarrhea. Pt in usual state of good health a.m. of 1/16/09 except for some recent mild congestion. Later noted to be sweaty and did not respond while parent was changing clothes. Later noted to be eye rolling and making unusual movements. In status epilepticus and metabolic acidosis on arrivial in local ED. Intubated and medicated for seizures and transferred to higher level of care. Cool and mottled on arrival. LFTs elevated. Issues with hypoglycemia, abnormal coags and electrolyte fluctuations with little response to tx. Parents elected to withdraw life support follwing notification of fatal status of illness. 2/12/09 Death Cert received. COD- Multiorgan Failure. Hemorrhagic Shock and Encephalopathy Syndrome.


Changed on 8/14/2018

VAERS ID: 337243 Before After
VAERS Form:1
Age:0.44
Sex:Male
Location:Pennsylvania
Vaccinated:2008-12-11
Onset:2008-12-16
Submitted:2009-01-09
Entered:2009-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2957AA / 2 UN / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF4U5AA / 2 UN / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 2 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH D01074 / 2 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0217X / 2 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Death, Encephalopathy, Shock haemorrhagic

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-18
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: Tylenol
Current Illness: None
Preexisting Conditions: None. PMH: none.
Allergies:
Diagnostic Lab Data: See attached. Labs and Diagnostics: CBC with 43K WBCs with 20% atypical lymphs. CT brain scan (+) cerebral edema and probable ischemic infarcts. CSF (+) for few PMNs, CSF glucose 105, CSF protein 62. CSF cx (-). EEG abnormal. Rotavirus (+), likely due to shedding. ALT 938-9,480. AST 1,974-12,822. Blood cx (-). UC (-). Hgb 9.2. Platelets WNL on admission down to 105K. Lactate 5.3 on adm up to 10.2. PT 36.3-49.5. INR 3.54-5.22. PTT 42-56. Fibrinogen dropped from 153-137. D-dimer $g 20. CXR (+) for atelectasis. K+ 6.1. CO2 12. Cl- 110. Glucose 55.
CDC 'Split Type':

Write-up: Patient developed hemorrhagic shock w/ encephalopathy syndrome 5 days after vaccine administration and died. 1/27/2009 MR received for DOS 12/16-18/2008 which was the Date of death. Principal DX: Multisystem organ failure 2'' to Hemorrhagic Shock and Encephalopathy Syndrome (HSES). Pt initially presented with new onset seizures and diarrhea. Pt in usual state of good health a.m. of 1/16/09 except for some recent mild congestion. Later noted to be sweaty and did not respond while parent was changing clothes. Later noted to be eye rolling and making unusual movements. In status epilepticus and metabolic acidosis on arrivial in local ED. Intubated and medicated for seizures and transferred to higher level of care. Cool and mottled on arrival. LFTs elevated. Issues with hypoglycemia, abnormal coags and electrolyte fluctuations with little response to tx. Parents elected to withdraw life support follwing notification of fatal status of illness. 2/12/09 Death Cert received. COD- Multiorgan Failure. Hemorrhagic Shock and Encephalopathy Syndrome.


Changed on 9/14/2018

VAERS ID: 337243 Before After
VAERS Form:1
Age:0.44
Sex:Male
Location:Pennsylvania
Vaccinated:2008-12-11
Onset:2008-12-16
Submitted:2009-01-09
Entered:2009-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2957AA / 2 UN / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF4U5AA / 2 UN / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 2 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH D01074 / 2 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0217X / 2 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Death, Encephalopathy, Shock haemorrhagic

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-18
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: Tylenol
Current Illness: None
Preexisting Conditions: None. PMH: none.
Allergies:
Diagnostic Lab Data: See attached. Labs and Diagnostics: CBC with 43K WBCs with 20% atypical lymphs. CT brain scan (+) cerebral edema and probable ischemic infarcts. CSF (+) for few PMNs, CSF glucose 105, CSF protein 62. CSF cx (-). EEG abnormal. Rotavirus (+), likely due to shedding. ALT 938-9,480. AST 1,974-12,822. Blood cx (-). UC (-). Hgb 9.2. Platelets WNL on admission down to 105K. Lactate 5.3 on adm up to 10.2. PT 36.3-49.5. INR 3.54-5.22. PTT 42-56. Fibrinogen dropped from 153-137. D-dimer $g 20. CXR (+) for atelectasis. K+ 6.1. CO2 12. Cl- 110. Glucose 55.
CDC 'Split Type':

Write-up: Patient developed hemorrhagic shock w/ encephalopathy syndrome 5 days after vaccine administration and died. 1/27/2009 MR received for DOS 12/16-18/2008 which was the Date of death. Principal DX: Multisystem organ failure 2'' to Hemorrhagic Shock and Encephalopathy Syndrome (HSES). Pt initially presented with new onset seizures and diarrhea. Pt in usual state of good health a.m. of 1/16/09 except for some recent mild congestion. Later noted to be sweaty and did not respond while parent was changing clothes. Later noted to be eye rolling and making unusual movements. In status epilepticus and metabolic acidosis on arrivial in local ED. Intubated and medicated for seizures and transferred to higher level of care. Cool and mottled on arrival. LFTs elevated. Issues with hypoglycemia, abnormal coags and electrolyte fluctuations with little response to tx. Parents elected to withdraw life support follwing notification of fatal status of illness. 2/12/09 Death Cert received. COD- Multiorgan Failure. Hemorrhagic Shock and Encephalopathy Syndrome.


Changed on 10/14/2018

VAERS ID: 337243 Before After
VAERS Form:1
Age:0.44
Sex:Male
Location:Pennsylvania
Vaccinated:2008-12-11
Onset:2008-12-16
Submitted:2009-01-09
Entered:2009-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2957AA / 2 UN / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF4U5AA / 2 UN / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 2 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH D01074 / 2 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0217X / 2 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Death, Encephalopathy, Shock haemorrhagic

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-18
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: Tylenol
Current Illness: None
Preexisting Conditions: None. PMH: none.
Allergies:
Diagnostic Lab Data: See attached. Labs and Diagnostics: CBC with 43K WBCs with 20% atypical lymphs. CT brain scan (+) cerebral edema and probable ischemic infarcts. CSF (+) for few PMNs, CSF glucose 105, CSF protein 62. CSF cx (-). EEG abnormal. Rotavirus (+), likely due to shedding. ALT 938-9,480. AST 1,974-12,822. Blood cx (-). UC (-). Hgb 9.2. Platelets WNL on admission down to 105K. Lactate 5.3 on adm up to 10.2. PT 36.3-49.5. INR 3.54-5.22. PTT 42-56. Fibrinogen dropped from 153-137. D-dimer $g 20. CXR (+) for atelectasis. K+ 6.1. CO2 12. Cl- 110. Glucose 55.
CDC 'Split Type':

Write-up: Patient developed hemorrhagic shock w/ encephalopathy syndrome 5 days after vaccine administration and died. 1/27/2009 MR received for DOS 12/16-18/2008 which was the Date of death. Principal DX: Multisystem organ failure 2'' to Hemorrhagic Shock and Encephalopathy Syndrome (HSES). Pt initially presented with new onset seizures and diarrhea. Pt in usual state of good health a.m. of 1/16/09 except for some recent mild congestion. Later noted to be sweaty and did not respond while parent was changing clothes. Later noted to be eye rolling and making unusual movements. In status epilepticus and metabolic acidosis on arrivial in local ED. Intubated and medicated for seizures and transferred to higher level of care. Cool and mottled on arrival. LFTs elevated. Issues with hypoglycemia, abnormal coags and electrolyte fluctuations with little response to tx. Parents elected to withdraw life support follwing notification of fatal status of illness. 2/12/09 Death Cert received. COD- Multiorgan Failure. Hemorrhagic Shock and Encephalopathy Syndrome.


Changed on 12/24/2020

VAERS ID: 337243 Before After
VAERS Form:1
Age:0.44
Sex:Male
Location:Pennsylvania
Vaccinated:2008-12-11
Onset:2008-12-16
Submitted:2009-01-09
Entered:2009-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2957AA / 2 UN / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF4U5AA / 2 UN / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 2 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH D01074 / 2 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0217X / 2 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Death, Encephalopathy, Shock haemorrhagic

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-18
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: Tylenol
Current Illness: None
Preexisting Conditions: None. PMH: none.
Allergies:
Diagnostic Lab Data: See attached. Labs and Diagnostics: CBC with 43K WBCs with 20% atypical lymphs. CT brain scan (+) cerebral edema and probable ischemic infarcts. CSF (+) for few PMNs, CSF glucose 105, CSF protein 62. CSF cx (-). EEG abnormal. Rotavirus (+), likely due to shedding. ALT 938-9,480. AST 1,974-12,822. Blood cx (-). UC (-). Hgb 9.2. Platelets WNL on admission down to 105K. Lactate 5.3 on adm up to 10.2. PT 36.3-49.5. INR 3.54-5.22. PTT 42-56. Fibrinogen dropped from 153-137. D-dimer $g 20. CXR (+) for atelectasis. K+ 6.1. CO2 12. Cl- 110. Glucose 55.
CDC 'Split Type':

Write-up: Patient developed hemorrhagic shock w/ encephalopathy syndrome 5 days after vaccine administration and died. 1/27/2009 MR received for DOS 12/16-18/2008 which was the Date of death. Principal DX: Multisystem organ failure 2'' to Hemorrhagic Shock and Encephalopathy Syndrome (HSES). Pt initially presented with new onset seizures and diarrhea. Pt in usual state of good health a.m. of 1/16/09 except for some recent mild congestion. Later noted to be sweaty and did not respond while parent was changing clothes. Later noted to be eye rolling and making unusual movements. In status epilepticus and metabolic acidosis on arrivial in local ED. Intubated and medicated for seizures and transferred to higher level of care. Cool and mottled on arrival. LFTs elevated. Issues with hypoglycemia, abnormal coags and electrolyte fluctuations with little response to tx. Parents elected to withdraw life support follwing notification of fatal status of illness. 2/12/09 Death Cert received. COD- Multiorgan Failure. Hemorrhagic Shock and Encephalopathy Syndrome.


Changed on 12/30/2020

VAERS ID: 337243 Before After
VAERS Form:1
Age:0.44
Sex:Male
Location:Pennsylvania
Vaccinated:2008-12-11
Onset:2008-12-16
Submitted:2009-01-09
Entered:2009-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2957AA / 2 UN / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF4U5AA / 2 UN / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 2 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH D01074 / 2 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0217X / 2 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Death, Encephalopathy, Shock haemorrhagic

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-18
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: Tylenol
Current Illness: None
Preexisting Conditions: None. PMH: none.
Allergies:
Diagnostic Lab Data: See attached. Labs and Diagnostics: CBC with 43K WBCs with 20% atypical lymphs. CT brain scan (+) cerebral edema and probable ischemic infarcts. CSF (+) for few PMNs, CSF glucose 105, CSF protein 62. CSF cx (-). EEG abnormal. Rotavirus (+), likely due to shedding. ALT 938-9,480. AST 1,974-12,822. Blood cx (-). UC (-). Hgb 9.2. Platelets WNL on admission down to 105K. Lactate 5.3 on adm up to 10.2. PT 36.3-49.5. INR 3.54-5.22. PTT 42-56. Fibrinogen dropped from 153-137. D-dimer $g 20. CXR (+) for atelectasis. K+ 6.1. CO2 12. Cl- 110. Glucose 55.
CDC 'Split Type':

Write-up: Patient developed hemorrhagic shock w/ encephalopathy syndrome 5 days after vaccine administration and died. 1/27/2009 MR received for DOS 12/16-18/2008 which was the Date of death. Principal DX: Multisystem organ failure 2'' to Hemorrhagic Shock and Encephalopathy Syndrome (HSES). Pt initially presented with new onset seizures and diarrhea. Pt in usual state of good health a.m. of 1/16/09 except for some recent mild congestion. Later noted to be sweaty and did not respond while parent was changing clothes. Later noted to be eye rolling and making unusual movements. In status epilepticus and metabolic acidosis on arrivial in local ED. Intubated and medicated for seizures and transferred to higher level of care. Cool and mottled on arrival. LFTs elevated. Issues with hypoglycemia, abnormal coags and electrolyte fluctuations with little response to tx. Parents elected to withdraw life support follwing notification of fatal status of illness. 2/12/09 Death Cert received. COD- Multiorgan Failure. Hemorrhagic Shock and Encephalopathy Syndrome.


Changed on 5/7/2021

VAERS ID: 337243 Before After
VAERS Form:1
Age:0.44
Sex:Male
Location:Pennsylvania
Vaccinated:2008-12-11
Onset:2008-12-16
Submitted:2009-01-09
Entered:2009-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2957AA / 2 UN / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF4U5AA / 2 UN / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 2 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH D01074 / 2 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0217X / 2 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Death, Encephalopathy, Shock haemorrhagic

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-18
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: Tylenol
Current Illness: None
Preexisting Conditions: None. PMH: none.
Allergies:
Diagnostic Lab Data: See attached. Labs and Diagnostics: CBC with 43K WBCs with 20% atypical lymphs. CT brain scan (+) cerebral edema and probable ischemic infarcts. CSF (+) for few PMNs, CSF glucose 105, CSF protein 62. CSF cx (-). EEG abnormal. Rotavirus (+), likely due to shedding. ALT 938-9,480. AST 1,974-12,822. Blood cx (-). UC (-). Hgb 9.2. Platelets WNL on admission down to 105K. Lactate 5.3 on adm up to 10.2. PT 36.3-49.5. INR 3.54-5.22. PTT 42-56. Fibrinogen dropped from 153-137. D-dimer $g 20. CXR (+) for atelectasis. K+ 6.1. CO2 12. Cl- 110. Glucose 55.
CDC 'Split Type':

Write-up: Patient developed hemorrhagic shock w/ encephalopathy syndrome 5 days after vaccine administration and died. 1/27/2009 MR received for DOS 12/16-18/2008 which was the Date of death. Principal DX: Multisystem organ failure 2'' to Hemorrhagic Shock and Encephalopathy Syndrome (HSES). Pt initially presented with new onset seizures and diarrhea. Pt in usual state of good health a.m. of 1/16/09 except for some recent mild congestion. Later noted to be sweaty and did not respond while parent was changing clothes. Later noted to be eye rolling and making unusual movements. In status epilepticus and metabolic acidosis on arrivial in local ED. Intubated and medicated for seizures and transferred to higher level of care. Cool and mottled on arrival. LFTs elevated. Issues with hypoglycemia, abnormal coags and electrolyte fluctuations with little response to tx. Parents elected to withdraw life support follwing notification of fatal status of illness. 2/12/09 Death Cert received. COD- Multiorgan Failure. Hemorrhagic Shock and Encephalopathy Syndrome.


Changed on 5/21/2021

VAERS ID: 337243 Before After
VAERS Form:1
Age:0.44
Sex:Male
Location:Pennsylvania
Vaccinated:2008-12-11
Onset:2008-12-16
Submitted:2009-01-09
Entered:2009-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2957AA / 2 UN / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF4U5AA / 2 UN / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 2 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH D01074 / 2 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0217X / 2 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Death, Encephalopathy, Shock haemorrhagic

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-18
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: Tylenol
Current Illness: None
Preexisting Conditions: None. PMH: none.
Allergies:
Diagnostic Lab Data: See attached. Labs and Diagnostics: CBC with 43K WBCs with 20% atypical lymphs. CT brain scan (+) cerebral edema and probable ischemic infarcts. CSF (+) for few PMNs, CSF glucose 105, CSF protein 62. CSF cx (-). EEG abnormal. Rotavirus (+), likely due to shedding. ALT 938-9,480. AST 1,974-12,822. Blood cx (-). UC (-). Hgb 9.2. Platelets WNL on admission down to 105K. Lactate 5.3 on adm up to 10.2. PT 36.3-49.5. INR 3.54-5.22. PTT 42-56. Fibrinogen dropped from 153-137. D-dimer $g 20. CXR (+) for atelectasis. K+ 6.1. CO2 12. Cl- 110. Glucose 55.
CDC 'Split Type':

Write-up: Patient developed hemorrhagic shock w/ encephalopathy syndrome 5 days after vaccine administration and died. 1/27/2009 MR received for DOS 12/16-18/2008 which was the Date of death. Principal DX: Multisystem organ failure 2'' to Hemorrhagic Shock and Encephalopathy Syndrome (HSES). Pt initially presented with new onset seizures and diarrhea. Pt in usual state of good health a.m. of 1/16/09 except for some recent mild congestion. Later noted to be sweaty and did not respond while parent was changing clothes. Later noted to be eye rolling and making unusual movements. In status epilepticus and metabolic acidosis on arrivial in local ED. Intubated and medicated for seizures and transferred to higher level of care. Cool and mottled on arrival. LFTs elevated. Issues with hypoglycemia, abnormal coags and electrolyte fluctuations with little response to tx. Parents elected to withdraw life support follwing notification of fatal status of illness. 2/12/09 Death Cert received. COD- Multiorgan Failure. Hemorrhagic Shock and Encephalopathy Syndrome.

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