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This is VAERS ID 485757

Case Details

VAERS ID: 485757 (history)  
Form: Version 1.0  
Age: 11.0  
Gender: Female  
Location: New York  
Vaccinated:2013-02-19
Onset:2013-02-19
   Days after vaccination:0
Submitted: 2013-02-25
   Days after onset:6
Entered: 2013-02-28
   Days after submission:3
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS AHAVB677CA / UNK UN / UN
HPV4: HPV (GARDASIL) / MERCK & CO. INC. H016238 / UNK UN / UN
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U42927 / UNK UN / UN
TDAP: TDAP (ADACEL) / SANOFI PASTEUR U4431BA / UNK UN / UN

Administered by: Private       Purchased by: Unknown
Symptoms: Cardiac arrest, Crying, Death, Endotracheal intubation, Respiratory arrest, Skin discolouration
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Angioedema (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Depression (excl suicide and self injury) (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2013-02-20
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: DILANTIN; Phenobarb
Current Illness: Medical record - cough - resp sym x 5 days (doc denies)
Preexisting Conditions: Microcephaly; seizure
Allergies:
Diagnostic Lab Data: See reverse
CDC Split Type:

Write-up: 2/19/13 23:24 Pt brought in by ambulance in cardiac arrest, "mother states pt has been having cough & URI symptoms since 5 days - seen by doctor 2/19/13 & given 4 vaccines. Pt sleeping & crying - suddenly pt turned white & was not breathing - 911 called & intubated. Doctor states he was not aware of any illness & child''s DILANTIN level was 1.0. No lab found in medical record child revived & transfer to another hospital where child died on 2/20/13.


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