National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

This is VAERS ID 420013

Government Disclaimer on use of this data

History of Changes from the VAERS Wayback Machine

First Appeared on 4/13/2011

VAERS ID: 420013
VAERS Form:
Age:0.8
Sex:Male
Location:Unknown
Vaccinated:2010-10-12
Onset:2011-03-15
Submitted:2011-03-30
Entered:2011-03-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C368AA / 1 UN / UN
FLU(10-11): INFLUENZA (SEASONAL) (FLUZONE 10-11) / SANOFI PASTEUR UT3575DA / 0 UN / UN
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVB24CA / 2 UN / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 914274 / 1 UN / IM

Administered by: Other      Purchased by: Other
Symptoms: Acute respiratory failure, Atrioventricular block, Bradycardia, Brain herniation, Brain hypoxia, Cardiac arrest, Cardiac pacemaker insertion, Cardiogenic shock, Cardiomegaly, Cardiomyopathy, Cardioversion, Cerebral ischaemia, Computerised tomogram abnormal, Convulsion, Culture tissue specimen positive, Death, Dehydration, Disseminated intravascular coagulation, Electrocardiogram QRS complex prolonged, Hypertension, Hypotension, Intensive care, Meningitis pneumococcal, Otitis media, Platelet count decreased, Pyrexia, Sepsis, Status epilepticus, Supraventricular tachycardia, Viral infection, Viral myocarditis, Vomiting, White blood cell count decreased, X-ray abnormal, Brain oedema, Autopsy, Neurological infection, Extracorporeal membrane oxygenation, Computerised tomogram head, Purulence, Mechanical ventilation, Endotracheal intubation, Streptococcus test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-03-15
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? 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.


Changed on 5/13/2011

VAERS ID: 420013 Before After
VAERS Form:
Age:0.8
Sex:Male
Location:Unknown
Vaccinated:2010-10-12
Onset:2011-03-15
Submitted:2011-03-30
Entered:2011-03-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C368AA / 1 UN / UN
FLU(10-11): INFLUENZA (SEASONAL) (FLUZONE 10-11) / SANOFI PASTEUR UT3575DA / 0 UN / UN
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVB24CA / 2 UN / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 914274 / 1 UN / IM

Administered by: Other      Purchased by: Other
Symptoms: Acute respiratory failure, Atrioventricular block, Bradycardia, Brain herniation, Brain hypoxia, Cardiac arrest, Cardiac pacemaker insertion, Cardiogenic shock, Cardiomegaly, Cardiomyopathy, Cardioversion, Cerebral ischaemia, Computerised tomogram abnormal, Convulsion, Culture tissue specimen positive, Death, Dehydration, Disseminated intravascular coagulation, Electrocardiogram QRS complex prolonged, Hypertension, Hypotension, Intensive care, Meningitis pneumococcal, Otitis media, Platelet count decreased, Pyrexia, Sepsis, Status epilepticus, Supraventricular tachycardia, Viral infection, Viral myocarditis, Vomiting, White blood cell count decreased, X-ray abnormal, Brain oedema, Autopsy, Neurological infection, Extracorporeal membrane oxygenation, Computerised tomogram head, Purulence, Mechanical ventilation, Endotracheal intubation, Streptococcus test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-03-15
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? 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.


Changed on 7/12/2011

VAERS ID: 420013 Before After
VAERS Form:
Age:0.8
Sex:Male
Location:Unknown
Vaccinated:2010-10-12
Onset:2011-03-15
Submitted:2011-03-30
Entered:2011-03-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C368AA / 1 UN / UN
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3575DA / 0 UN / UN
FLU(10-11): INFLUENZA (SEASONAL) (FLUZONE 10-11) / SANOFI PASTEUR UT3575DA / 0 UN / UN
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVB24CA / 2 UN / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 914274 / 1 UN / IM

Administered by: Other      Purchased by: Other
Symptoms: Cardiac arrest, Cardiomegaly, Convulsion, Culture tissue specimen positive, Death, Meningitis pneumococcal, Pyrexia, Viral myocarditis, Vomiting, X-ray abnormal, Autopsy, Neurological infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-03-15
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? 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.


Changed on 7/7/2013

VAERS ID: 420013 Before After
VAERS Form:
Age:0.8
Sex:Male
Location:Unknown
Vaccinated:2010-10-12
Onset:2011-03-15
Submitted:2011-03-30
Entered:2011-03-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C368AA / 1 UN / UN
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3575DA / 0 UN / UN
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3575DA / 0 UN / UN
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVB24CA / 2 UN / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 914274 / 1 UN / IM

Administered by: Other      Purchased by: Other
Symptoms: Cardiac arrest, Cardiomegaly, Convulsion, Culture tissue specimen positive, Death, Meningitis pneumococcal, Pyrexia, Viral myocarditis, Vomiting, X-ray abnormal, Autopsy, Neurological infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-03-15
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? 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.


Changed on 6/14/2014

VAERS ID: 420013 Before After
VAERS Form:
Age:0.8
Sex:Male
Location:Unknown
Vaccinated:2010-10-12
Onset:2011-03-15
Submitted:2011-03-30
Entered:2011-03-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C368AA / 1 UN / UN
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3575DA / 0 UN / UN
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVB24CA / 2 UN / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 914274 / 1 UN / IM

Administered by: Other      Purchased by: Other
Symptoms: Cardiac arrest, Cardiomegaly, Convulsion, Culture tissue specimen positive, Death, Meningitis pneumococcal, Pyrexia, Viral myocarditis, Vomiting, X-ray abnormal, Autopsy, Neurological infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-03-15
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? 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.


Changed on 2/14/2017

VAERS ID: 420013 Before After
VAERS Form:
Age:0.8 0.84
Sex:Male
Location:Unknown
Vaccinated:2010-10-12
Onset:2011-03-15
Submitted:2011-03-30
Entered:2011-03-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C368AA / 1 UN / UN
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3575DA / 0 UN / UN
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVB24CA / 2 UN / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 914274 / 1 UN / IM

Administered by: Other      Purchased by: Other
Symptoms: Cardiac arrest, Cardiomegaly, Convulsion, Culture tissue specimen positive, Death, Meningitis pneumococcal, Pyrexia, Viral myocarditis, Vomiting, X-ray abnormal, Autopsy, Neurological infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-03-15
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? Yes, days:     Extended hospital stay? Yes
Previous Vaccinations:
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.


Changed on 4/14/2017

VAERS ID: 420013 Before After
VAERS Form:
Age:0.84
Sex:Male
Location:Unknown
Vaccinated:2010-10-12
Onset:2011-03-15
Submitted:2011-03-30
Entered:2011-03-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C368AA / 1 UN / UN
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3575DA / 0 UN / UN
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVB24CA / 2 UN / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 914274 / 1 UN / IM

Administered by: Other      Purchased by: Other
Symptoms: Cardiac arrest, Cardiomegaly, Convulsion, Culture tissue specimen positive, Death, Meningitis pneumococcal, Pyrexia, Viral myocarditis, Vomiting, X-ray abnormal, Autopsy, Neurological infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-03-15
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? 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.


Changed on 9/14/2017

VAERS ID: 420013 Before After
VAERS Form:(blank) 1
Age:0.84
Sex:Male
Location:Unknown
Vaccinated:2010-10-12
Onset:2011-03-15
Submitted:2011-03-30
Entered:2011-03-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C368AA / 1 2 UN / UN
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3575DA / 0 1 UN / UN
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVB24CA / 2 3 UN / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 914274 / 1 2 UN / IM

Administered by: Other      Purchased by: Other
Symptoms: Cardiac arrest, Cardiomegaly, Convulsion, Culture tissue specimen positive, Death, Meningitis pneumococcal, Pyrexia, Viral myocarditis, Vomiting, X-ray abnormal, Autopsy, Neurological infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-03-15
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? 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.


Changed on 2/14/2018

VAERS ID: 420013 Before After
VAERS Form:1
Age:0.84
Sex:Male
Location:Unknown
Vaccinated:2010-10-12
Onset:2011-03-15
Submitted:2011-03-30
Entered:2011-03-31
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: Cardiac arrest, Cardiomegaly, Convulsion, Culture tissue specimen positive, Death, Meningitis pneumococcal, Pyrexia, Viral myocarditis, Vomiting, X-ray abnormal, Autopsy, Neurological infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-03-15
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? 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.


Changed on 6/14/2018

VAERS ID: 420013 Before After
VAERS Form:1
Age:0.84
Sex:Male
Location:Unknown
Vaccinated:2010-10-12
Onset:2011-03-15
Submitted:2011-03-30
Entered:2011-03-31
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: Cardiac arrest, Cardiomegaly, Convulsion, Culture tissue specimen positive, Death, Meningitis pneumococcal, Pyrexia, Viral myocarditis, Vomiting, X-ray abnormal, Autopsy, Neurological infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-03-15
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? 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.


Changed on 8/14/2018

VAERS ID: 420013 Before After
VAERS Form:1
Age:0.84
Sex:Male
Location:Unknown
Vaccinated:2010-10-12
Onset:2011-03-15
Submitted:2011-03-30
Entered:2011-03-31
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: Cardiac arrest, Cardiomegaly, Convulsion, Culture tissue specimen positive, Death, Meningitis pneumococcal, Pyrexia, Viral myocarditis, Vomiting, X-ray abnormal, Autopsy, Neurological infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-03-15
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? 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.


Changed on 9/14/2018

VAERS ID: 420013 Before After
VAERS Form:1
Age:0.84
Sex:Male
Location:Unknown
Vaccinated:2010-10-12
Onset:2011-03-15
Submitted:2011-03-30
Entered:2011-03-31
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: Cardiac arrest, Cardiomegaly, Convulsion, Culture tissue specimen positive, Death, Meningitis pneumococcal, Pyrexia, Viral myocarditis, Vomiting, X-ray abnormal, Autopsy, Neurological infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-03-15
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? 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.


Changed on 10/14/2018

VAERS ID: 420013 Before After
VAERS Form:1
Age:0.84
Sex:Male
Location:Unknown
Vaccinated:2010-10-12
Onset:2011-03-15
Submitted:2011-03-30
Entered:2011-03-31
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: Cardiac arrest, Cardiomegaly, Convulsion, Culture tissue specimen positive, Death, Meningitis pneumococcal, Pyrexia, Viral myocarditis, Vomiting, X-ray abnormal, Autopsy, Neurological infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-03-15
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? 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.


Changed on 12/24/2020

VAERS ID: 420013 Before After
VAERS Form:1
Age:0.84
Sex:Male
Location:Unknown
Vaccinated:2010-10-12
Onset:2011-03-15
Submitted:2011-03-30
Entered:2011-03-31
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: Cardiac arrest, Cardiomegaly, Convulsion, Culture tissue specimen positive, Death, Meningitis pneumococcal, Pyrexia, Viral myocarditis, Vomiting, X-ray abnormal, Autopsy, Neurological infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-03-15
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? 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.


Changed on 12/30/2020

VAERS ID: 420013 Before After
VAERS Form:1
Age:0.84
Sex:Male
Location:Unknown
Vaccinated:2010-10-12
Onset:2011-03-15
Submitted:2011-03-30
Entered:2011-03-31
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: Cardiac arrest, Cardiomegaly, Convulsion, Culture tissue specimen positive, Death, Meningitis pneumococcal, Pyrexia, Viral myocarditis, Vomiting, X-ray abnormal, Autopsy, Neurological infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-03-15
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? 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.


Changed on 5/7/2021

VAERS ID: 420013 Before After
VAERS Form:1
Age:0.84
Sex:Male
Location:Unknown
Vaccinated:2010-10-12
Onset:2011-03-15
Submitted:2011-03-30
Entered:2011-03-31
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: Cardiac arrest, Cardiomegaly, Convulsion, Culture tissue specimen positive, Death, Meningitis pneumococcal, Pyrexia, Viral myocarditis, Vomiting, X-ray abnormal, Autopsy, Neurological infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-03-15
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? 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.


Changed on 5/14/2021

VAERS ID: 420013 Before After
VAERS Form:1
Age:0.84
Sex:Male
Location:Unknown
Vaccinated:2010-10-12
Onset:2011-03-15
Submitted:2011-03-30
Entered:2011-03-31
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: Cardiac arrest, Cardiomegaly, Convulsion, Culture tissue specimen positive, Death, Meningitis pneumococcal, Pyrexia, Viral myocarditis, Vomiting, X-ray abnormal, Autopsy, Neurological infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-03-15
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? 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.

New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=420013&WAYBACKHISTORY=ON


Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166