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From the 11/12/2021 release of VAERS data:

This is VAERS ID 420013

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Case Details

VAERS ID: 420013 (history)  
Form: Version 1.0  
Age: 0.84  
Sex: Male  
Location: Unknown  
Vaccinated:2010-10-12
Onset:2011-03-15
   Days after vaccination:154
Submitted: 2011-03-30
   Days after onset:15
Entered: 2011-03-31
   Days after submission:1
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C368AA / 2 UN / UN
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3575DA / 1 UN / UN
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVB24CA / 3 UN / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 914274 / 2 UN / IM

Administered by: Other       Purchased by: Other
Symptoms: Autopsy, Cardiac arrest, Cardiomegaly, Convulsion, Culture tissue specimen positive, Death, Meningitis pneumococcal, Neurological infection, Pyrexia, Viral myocarditis, Vomiting, X-ray abnormal
SMQs:, Torsade de pointes/QT prolongation (broad), Cardiac failure (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Convulsions (narrow), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Generalised convulsive seizures following immunisation (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2011-03-15
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: No other medications
Current Illness: Unknown
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: X-ray (14-MAR-2011) results: showed he had an enlarged heart; Autopsy - brain tissue culture (15Mar2011) revealed: pneumococcal meningitis
CDC Split Type: 2011066068

Write-up: This is a spontaneous report from a Pfizer sales representative on behalf of a contactable physician. A 15-month-old male (at the time of death) received the first dose of PREVNAR 13 on an unknown date in JUL2010 at 0.5ml, and the second dose on an unknown date in Oct2010, to prevent against pneumococcal disease. Relevant medical history was unknown. The relevant concomitant medications were unknown. The infant had only been administered two doses of PREVNAR 13 instead of four doses. On 11MAR2011, he was taken to the Emergency Room and diagnosed with neural infection. Treatment was not reported. On 13MAR2011, the patient was taken to the Emergency Room again, but did not see the doctor came back home. On 14MAR2011, the patient was taken to the physician''s office, where he presented with fever, vomiting, and neural infection, because of which he was hospitalized. On 14MAR2011, while in the hospital, he had seizures. An x-ray was performed which revealed an enlarged heart. The patient then had cardiac arrest. On 14MAR2011, the patient was transferred to a hospital where they have found viral myocarditis. Treatments in response to the events were not reported. On 15MAR2011, the infant died. An autopsy was performed on brain tissue culture on 15MAR2011, which showed that he died due to pneumococcal meningitis. The clinical outcome of the reported event of pneumococcal meningitis (per autopsy results) was fatal, and the outcome of the other events was unknown. Based on the information provided in the case, this individual report would not seem to modify the benefit/risk profile of PREVNAR 13.


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