Age: 0.2
Sex: M
Vaccine: DTAPHEPBIP, HIBV, PNC, RV5
Symptoms: Irritability, Lethargy, Mental status changes, Oropharyngeal plaque, Pneumonia
Clinical narrative: Information has been received from a physician and medical records concerning an approximately 3 month old male with rash erythematous, bronchiolitis and upper respiratory tract infection and a history of nervous system disorder, brain malformation, cardiac murmur, contusion, cough, ear infection, feeding disorder neonatal, jaundice neonatal, milia, pyrexia, seborrhoeic dermatitis and upper respiratory tract congestion who on 26-NOV-2007 presented with red bumps on his face to the physician, though no diagnosis was recorded by the physician. The infant's visit was assessed as a well child visit, and he was vaccinated with the first dose of ROTATEQ (dose # not specified), with the first dose, IM, of PEDVAXHIB (manufacturer unspecified), with a dose of PREVNAR, and with a dose of PEDIARIX. On 24-DEC-2007, the mother brought her son to the ER with symptoms that had started one day prior, that included a runny nose, congestion, wheezing, cough and diarrhea. A chest x-ray result indicated "chest is unremarkable." Treatment included AMOXIL. The infant was diagnosed with pneumonia, and was discharged to home, with instructions to follow up with the family doctor within 3-4 days. On 31-DEC-2007, the infant was seen by the physician for follow up, and had continued congestion and white plaques in the mouth (2-3 weeks). The physician indicated that NYSTATIN had been previously ordered for thrush, but without improvement. The mother noted the infant was "jittery" after breathing treatments, so she stopped them "last night." The physician ordered OMNICEF. On 05-JAN-2008, a referral was given for the infant to be evaluated for hospitalization, due to gastroenteritis. The mother and father brought their son to the ER with vomiting, diarrhea and fever. It was documented that both AMOXIL and OMNICEF had been completed earlier in the week (previous diagnosis of pneumonia, and current medications included NYSTATIN, fluconazole and XOPENEX UD. He was hospitalized and diagnosed with acute gastroenteritis and viral syndrome. Treatment included PEDIALYTE for the next 12 hours, with instructions to follow up with the family doctor. The infant was discharged to home. On 06-JAN-2008, the mother returned with her son to the ER, and the "decision was made to admit him to the hospital for intravenous fluids." The infant "was noted to have copious amounts of watery diarrhea, very intake for approximately the first 36 hours of his hospitalization. On 08-JAN-2008, he was eating better, his IV was removed,  and he was discharged to home (On 10-JAN-2008, the physician noted that the patient had been hospitalized for 3 days). The discharge diagnosis was noninfectious gastroenteritis and colitis; discharge medication included over-the-counter LACTINEX granules. On 10-JAN-2008, the infant was brought to the clinic for follow up, and his mother stated that he had a new onset of vomiting during the night with copious amounts of diarrhea, "more than 20 diapers in the last 24 hours." The physician ordered ZANTAC. The infant was then take to the ER, and the hospital records indicated "on physical exam, on presentation, revealed a well appearing baby, in no acute distress." The infant was admitted to the hospital overnight for observation, with strict input and output (I & O), and to document the number of stools. The physician documented that she spoke with the mother "about postpartum depression and that this may be coloring her interpretation of the patient's symptoms, and I have counseled her about seeking care with her primary care physician." On 11-JAN-2008, the infant was discharged to home, and discharge diagnosis remained as gastroenteritis. On 18-JAN-2008, the infant, at 4 months of age, was taken to hospital for excessive lethargy. The history and physical, indicated that his mother stated he "fell asleep at his regular time but did not wake up until 10 o'clock this morning which was unusual for him." She felt that his level of alertness was decreased, so she took him to the first hospital. He was found to have altered mental status and was transferred to the treating hospital and admitted. He "presented with what appeared to be oral automatisms and decreased responsiveness." Treatment included IV fosphenytoin, which brought resolution of the symptoms. The history confirmed a normal and uncomplicated birth, and the patient had been "feeding and meeting his milestones prior to the diagnosis and following the diagnosis of cephalea." It was noted that "while seizing his blood pressure was elevated 135/50, satting 100% throughout." "No dysmorphic features were notable except for mild tinting of the mouth." The physician noted the heart sounds as regular (no murmur noted). The hospital physician's felt: "This is a 4 month old with neuronal migrational disorder of schizencephalic type who presents with what appears to be new onset seizure activity, presumably attributed to his brain malformation." He was admitted for continuous video electroencephalogy monitoring (EEG). Treatment included TRILEPTAL and clonazepam. The physician order a DILANTIN trough level in the morning, if he had breakthrough seizure activity, "so that we may bolus with DILANTIN, "but stated she did "not plan on keeping him on DILANTIN. TYLENOL was administered prn for pain and agitation. On 22-JAN-2008, the mother brought her son to the physician for follow up. His mother explained that on 18-JAN-2008 he had a seizure at home, and would not wake up as usual. She reported his eyes were open, but he was "lifeless" and didn't respond, so she called 911 and took him to an ER, and started that he had 3 seizures while at the hospital. The physician assessed the visit as a well child visit, and the infant was then vaccinated with second dose, of ROTATEQ (dose # not specified), with the second dose, IM, of PEDVAXHIB (manufacturer unspecified), with a PREVNAR, and with a dose of PEDIARIX. The physician noted that there were "no problems with previous immunizations." On 05-FEB-2008, the infant visited the office with a runny nose, cough and congestion (2 day prior onset). He was diagnosed with an upper respiratory infection, with no fever noted. On 10-FEB-2008, the infant was brought to the ER with a generalized rash and wheezing, onset 1 day prior. The physician noted that the infant had schizencephaly with a history of seizures. The infant was diagnosed with viral syndrome and viral exanthema and was discharged to home. Follow up was recommended with the physician in 3-4 days. On 12-FEB-2008, the infant again visited the physician with reports of rapid breathing and wheezing, with chest auscultation noted as clear. Treatment included ORAPRED, saline nasal drops, humidifier and elevate head of bed. An xray of the chest due to continued wheezing, showed results indicating "basically unremarkable and unchanged from an unremarkable exam of 10-JAN-2008." On 13-FEB-2008, the infant was brought to the ER with difficulty breathing, wheezing, and cough, onset 3 days prior. He was treated with VENTOLIN syrup and TYLENOL; a diagnosis of respiratory syncytial virus (RSV) bronchiolitis was determined. Aggressive use of home nebulizer, XOPENEX and more frequent suctioning was instructed, follow up with family doctor in 2-3days; discharged to home. On 15-FEB-2008, at a follow up visit, and was still wheezing, though better. Treatment included PULMICORT respules. On 23-FEB-2008, the infant was brought to the ER with fever, cough, congestion, a few bumps on his face and fussiness, worsened in the last 24-48 hours. Medications were noted as TYLENOL, TRILEPTAL, carbinoxamine plus pseudoephedrine and CARDEC and XOPENEX. The infant was diagnosed with Influenza B, supported by diagnostic immunology, and bronchiolitis, supported by chest xray. Treatment included MOTRIN, continue current medications and return if a worsening of symptoms. The infant was discharged to home with follow up instruction to see the physician within 5-7 days. On 28-FEB-2008, the infant was seen in follow up by the physician, with breathing treatments continued, and not seizures noted. Treatment with XOPENEX continued, and PULMICORT was added. On 03-MAR-2008, the infant was brought to the physician with fussiness, fever of 101.1, gassiness and not eating. Treatment included LEVSIN, with a diagnosis of abdominal pain, and a referral for gastroenterology evaluation. An x-ray of the abdomen was performed for complaints of abdominal pain. The result indicated "probable localized ileus." On 14-MAR-2008, the patient was seen by the physician, with "pus coming out of the left puncta," with no fever. Conjunctivitis, acute was diagnosed. Treatment included VIGAMOX eye drops. Follow up information from the nurse, indicated that in January of 2008, the child had a neurology consult; however, additional follow up information confirmed there had been no neurology consult. Follow up information in the form of medical records from a neurology exam, performed on 11-MAR-2008 were received (aged 5 1/2 months). The neurologist documented that the infant had a history "notable for an interval ear infection, as well as RSV bronchiolitis. The infant was reported to be a "well-appearing child," with regular heart sounds. The neurologic exam indicated: "he was diffuse low tone. Does bring his hands to midline, but is not rolling over. He has relatively good head control, his reflexes are brisk and symmetric. He moves all extremities symmetrically. He smile. He tracks." The neurologist's impression was "lesion-related epilepsy secondary to bilateral schizencephaly with evidence of mild motor delay and tone abnormalities" (referred to new-onset seizures in January). Therapy continued with TRILEPTAL; no breakthrough seizures since discharge, with referral for Early Childhood Intervention and genetics for family counseling; follow up in 3 months. Follow up information received from the mother's OB/GYN indicated the office did not notice any abnormalities before the baby was born. However, the baby started presenting with some abnormalities after he was born. His head was larger than it was supposed to be. This is one of several reports from the same source (WAES #0702USA03013). Additional information is not expected. All available medical records will be provided upon request.