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This is VAERS ID 475000

Case Details

VAERS ID: 475000 (history)  
Form: Version 1.0  
Age: 0.35  
Sex: Male  
Location: Virginia  
Vaccinated:2012-11-16
Onset:2012-11-16
   Days after vaccination:0
Submitted: 2012-11-19
   Days after onset:3
Entered: 2012-11-21
   Days after submission:2
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C4259AA / 2 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 918131 / 2 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41CB291A / 2 MO / PO

Administered by: Public       Purchased by: Public
Symptoms: Pyrexia
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2012-11-19
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Hydronephrosis; Fussy infant/baby
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt. was taken to the hospital for sx''s of high fever. Seen by resident.


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