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This is VAERS ID 718104

Case Details

VAERS ID: 718104 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Vermont  
Vaccinated:2017-10-02
Onset:2017-10-03
   Days after vaccination:1
Submitted: 2017-10-04
   Days after onset:1
Entered: 2017-10-05
   Days after submission:1
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPV: DTAP + IPV (KINRIX) / GLAXOSMITHKLINE BIOLOGICALS AF543 / UNK RA / UN
FLU4: INFLUENZA (SEASONAL) (FLUZONE QUADRIVALENT) / SANOFI PASTEUR UI864AA / 3 RA / UN
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS 954G2 / 2 LA / UN
MMRV: MEASLES + MUMPS + RUBELLA + VARICELLA (PROQUAD) / MERCK & CO. INC. N013863 / UNK LA / SC

Administered by: Public       Purchased by: Public
Symptoms: Erythema, Injection site rash, Pruritus, Pyrexia, Rash, Swelling, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Angioedema (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: NAS; Undescended (L) tests; IUGR
Allergies:
Diagnostic Lab Data: None ordered
CDC Split Type:

Write-up: Vaccines given on 10-2-17 (L) deltoid: Hep A - (L) arm; MMRV - RN. (R) deltoid: KINRIX and FLUZONE - RN. Seen in office 10-4-17 with rash on (Rt) deltoid, (Lt) arm and (L) forehead - reddened, localized swelling and itching. Fever/vomiting in less than 24 hours. Unknown if vaccine related.


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