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

This is VAERS ID 422268

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Case Details

VAERS ID: 422268 (history)  
Form: Version 1.0  
Age: 0.82  
Sex: Male  
Location: Texas  
Vaccinated:2011-02-17
Onset:2011-02-18
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2011-05-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS AC20B172AA / 4 UN / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915192 / 4 UN / UN

Administered by: Private       Purchased by: Private
Symptoms: Crying, Death, Decreased appetite, Infantile spitting up, Pyrexia, Somnolence
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Depression (excl suicide and self injury) (broad), Neonatal disorders (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2011-02-23
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Ear infection
Preexisting Conditions: Immunology problems undiagnosed
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: He was administered the shot and by the next day started having fevers & spitting up his food. His fever got worse and his appetite also. He was sleeping & crying for the most part and his fever was being stabilized by MOTRIN and TYLENOL.


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