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From the 6/11/2021 release of VAERS data:

This is VAERS ID 406922



Case Details

VAERS ID: 406922 (history)  
Form: Version 1.0  
Age: 0.58  
Sex: Female  
Location: New Hampshire  
Vaccinated:2010-04-30
Onset:2010-05-02
   Days after vaccination:2
Submitted: 2010-11-04
   Days after onset:186
Entered: 2010-11-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3600AA / 3 UN / UN
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1275Y / 3 UN / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH E44433 / 1 UN / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1588Y / 3 UN / UN

Administered by: Private       Purchased by: Public
Symptoms: Cardiac arrest, Congenital torticollis, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Congenital, familial and genetic disorders (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Ocular motility disorders (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2010-05-02
   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: SYNERGIS
Current Illness: none
Preexisting Conditions: NKA
Allergies:
Diagnostic Lab Data:
CDC Split Type: NH11042010

Write-up: Preterm; congenital torticollis presented unresponsive, cardiac arrest.


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