Source: https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=250332&WAYBACKHISTORY=ON
Timestamp: 2019-08-23 11:11:57
Document Index: 470769431

Matched Legal Cases: ['art 11', 'art 11', 'art 11', 'art 11', 'art 11', 'art 11', 'art 11', 'art 11']

This is VAERS ID 250332
VAERS ID: 250332
Vaccinated: 2004-11-23
Onset: 2004-11-30
Submitted: 2006-01-13
Entered: 2006-01-13
FLU: INFLUENZA (FLUZONE) / AVENTIS PASTEUR, INC. U1501AA / 0 - / IM
HEPA: HEP A (UNKNOWN MFR) / UNKNOWN MANUFACTURER AHABA015AA / 1 - / -
IPV: POLIO VIRUS, INACT. (IPOL) / AVENTIS PASTEUR, INC. X0706 / 0 - / SC
MEN: MENINGOCOCCAL POLYSACCHARIDE / UNKNOWN MANUFACTURER UE122AA / 0 - / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0781P / 0 - / SC
TD: TD ADSORBED, ADULT (NO BRAND NAME) / AVENTIS PASTEUR, INC. 01282AA / 0 - / IM
Symptoms: Asthma, Chest pain, Cough, Loss of consciousness, Myocarditis
Date died:2005-02-17
Preexisting Conditions: Asthma age 5
Diagnostic Lab Data: 18 Feb 05: Cardiac-normal distribution of small patent coronary arteries. The valves appear normal. The myocardium does not show any acute changes. The left ventricle measures 1.4 cm in thickness. The septum measures 1.4 cm in thickness. Th
Write-up: The Department of Health informed the VHC in May 05 of the death of a medically discharged service member. The service member enlisted in Nov 04, medically discharged in Jan 05, and died on Feb 17th. The following HPI is an account of the events prior to"his death as recalled by his mother during an interview in May 05. The service member a 20 year old male, who received his enlistment vaccines on 23 Nov 04. While speaking with his morn on 30 Nov he mentioned that he had a cough, and some chest pain. She
VAERS ID: 250332 Before After
FLU: INFLUENZA (FLUZONE) INFLUENZA (SEASONAL) (FLUZONE) / AVENTIS PASTEUR, INC. AVENTIS PASTEUR U1501AA / 0 - / IM
HEPA: HEP A (UNKNOWN MFR) HEP A (NO BRAND NAME) / UNKNOWN MANUFACTURER AHABA015AA / 1 - / -
IPV: POLIO VIRUS, INACT. (IPOL) / AVENTIS PASTEUR, INC. AVENTIS PASTEUR X0706 / 0 - / SC
MEN: MENINGOCOCCAL POLYSACCHARIDE MENINGOCOCCAL (NO BRAND NAME) / UNKNOWN MANUFACTURER UE122AA / 0 - / SC
TD: TD ADSORBED, ADULT (NO BRAND NAME) TD ADSORBED (NO BRAND NAME) / AVENTIS PASTEUR, INC. AVENTIS PASTEUR 01282AA / 0 - / IM
Administered by: Military Purchased by: Unknown Military
Symptoms: Asthma, Chest pain, Cough, Loss of consciousness, Myocarditis, Nasal congestion, Oedema
Write-up: The Department of Health informed the VHC in May 05 of the death of a medically discharged service member. The service member enlisted in Nov 04, medically discharged in Jan 05, and died on Feb 17th. The following HPI is an account of the events prior to"his to his death as recalled by his mother during an interview in May 05. The service member a 20 year old male, who received his enlistment vaccines on 23 Nov 04. While speaking with his morn on 30 Nov he mentioned that he had a cough, and some chest pain. She state that she encourage him to seek medical attention. She state that a couple of days later, while he was running he ''passed out'' and when he went to the doctor he was told it was asthma. Mom reported that while he was at home during Christmas, he reported to his family that he was experiencing some chest pain, and did have bumps on his face that cleared in Jan. Mom was unaware of which vaccines her son received but did remember that her son said that the needle was "funny." Mom does not recall if he had a scar on his arm. She state that he was discharged for stress related issues and complaints of chest pain. Mom is unaware of any other details regarding her son''s illness during that time only that the chest pain persisted. When questioned about his past history of asthma, she mentioned that he had it a little in childhood but has not been bothered by it since that time. She did mention that her son felt that his pain was not related to asthma. Mom was also questioned about the waiver for a medical exam upon discharge. She state that he was told that if he requested a workup, it would delay his release and that they may not even discharge him. He received his enlistment vaccines of Hep A-Hep B, Influenza, Meningococcal, MRR, Polio, and Td on 23 Nov 04 and he received his second Hep A-Hep B on 5 Jan 05. Chest pain start 11/30/2004, dyspnea (shortness of breath) start 11/30/2004. 4/3/06 Received Autopsy Report which revealed COD as chronic myocarditis.
FLU: INFLUENZA (SEASONAL) (FLUZONE) / AVENTIS PASTEUR SANOFI PASTEUR U1501AA / 0 - / IM
HEPA: HEP A (NO BRAND NAME) / UNKNOWN MANUFACTURER AHABA015AA / 1 - / -
IPV: POLIO VIRUS, INACT. (IPOL) / AVENTIS PASTEUR SANOFI PASTEUR X0706 / 0 - / SC
MEN: MENINGOCOCCAL (NO BRAND NAME) / UNKNOWN MANUFACTURER UE122AA / 0 - / SC
TD: TD ADSORBED (NO BRAND NAME) / AVENTIS PASTEUR SANOFI PASTEUR 01282AA / 0 - / IM
Write-up: The Department of Health informed the VHC in May 05 of the death of a medically discharged service member. The service member enlisted in Nov 04, medically discharged in Jan 05, and died on Feb 17th. The following HPI is an account of the events prior to his death as recalled by his mother during an interview in May 05. The service member a 20 year old male, who received his enlistment vaccines on 23 Nov 04. While speaking with his morn on 30 Nov he mentioned that he had a cough, and some chest pain. She state that she encourage him to seek medical attention. She state that a couple of days later, while he was running he ''passed out'' and when he went to the doctor he was told it was asthma. Mom reported that while he was at home during Christmas, he reported to his family that he was experiencing some chest pain, and did have bumps on his face that cleared in Jan. Mom was unaware of which vaccines her son received but did remember that her son said that the needle was "funny." Mom does not recall if he had a scar on his arm. She state that he was discharged for stress related issues and complaints of chest pain. Mom is unaware of any other details regarding her son''s illness during that time only that the chest pain persisted. When questioned about his past history of asthma, she mentioned that he had it a little in childhood but has not been bothered by it since that time. She did mention that her son felt that his pain was not related to asthma. Mom was also questioned about the waiver for a medical exam upon discharge. She state that he was told that if he requested a workup, it would delay his release and that they may not even discharge him. He received his enlistment vaccines of Hep A-Hep B, Influenza, Meningococcal, MRR, Polio, and Td on 23 Nov 04 and he received his second Hep A-Hep B on 5 Jan 05. Chest pain start 11/30/2004, dyspnea (shortness of breath) start 11/30/2004. 4/3/06 Received Autopsy Report which revealed COD as chronic myocarditis.
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U1501AA / 0 - / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0706 / 0 - / SC
TD: TD ADSORBED (NO BRAND NAME) / SANOFI PASTEUR 01282AA / 0 - / IM
Diagnostic Lab Data: 18 Feb 05: Cardiac-normal distribution of small patent coronary arteries. The valves appear normal. The myocardium does not show any acute changes. The left ventricle measures 1.4 cm in thickness. The septum measures 1.4 cm in thickness. Th The aorta has youthful intima. Resp-prominent congestion and mild edema without any discrete lesion. The airways patent. The vasculature free of thromboemboli. Microscopic Exam: Heart the mural sections show rare perivascular mononuclear cells some with plasmacytoid features. The AV node section shows extensive infiltration with mononuclear cells many of which are necrotic. Lung there is edema and congestion with focal mild interstitial chronic inflammation and proliferation of pigmented alveolar macrophage
Age: 21.0 20.0
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U1501AA / 0 - UN / IM
HEPA: HEP A (NO BRAND NAME) / UNKNOWN MANUFACTURER AHABA015AA / 1 - UN / - UN
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0706 / 0 - UN / SC
MEN: MENINGOCOCCAL (NO BRAND NAME) / UNKNOWN MANUFACTURER UE122AA / 0 - UN / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0781P / 0 - UN / SC
TD: TD ADSORBED (NO BRAND NAME) / SANOFI PASTEUR 01282AA / 0 - UN / IM
Diagnostic Lab Data: 18 Feb 05: Cardiac-normal distribution of small patent coronary arteries. The valves appear normal. The myocardium does not show any acute changes. The left ventricle measures 1.4 cm in thickness. The septum measures 1.4 cm in thickness. The aorta has youthful intima. Resp-prominent congestion and mild edema without any discrete lesion. The airways patent. The vasculature free of thromboemboli. Microscopic Exam: Heart the mural sections show rare perivascular mononuclear cells some with plasmacytoid features. The AV node section shows extensive infiltration with mononuclear cells many of which are necrotic. Lung there is edema and congestion with focal mild interstitial chronic inflammation and proliferation of pigmented alveolar macrophage
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U1501AA / 0 UN / IM
HEPA: HEP A (NO BRAND NAME) / UNKNOWN MANUFACTURER AHABA015AA / 1 UN / UN
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0706 / 0 UN / SC
MEN: MENINGOCOCCAL (NO BRAND NAME) / UNKNOWN MANUFACTURER UE122AA / 0 UN / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0781P / 0 UN / SC
TD: TD ADSORBED (NO BRAND NAME) / SANOFI PASTEUR 01282AA / 0 UN / IM
Write-up: The Department of Health informed the VHC HC in May 05 of the death of a medically discharged service member. patient. The service member patient enlisted in Nov 04, medically discharged in Jan 05, and died on Feb 17th. The following HPI is an account of the events prior to his death as recalled by his mother during an interview in May 05. The service member a 20 year old male, who received his enlistment vaccines on 23 Nov 04. While speaking with his morn mom on 30 Nov he mentioned that he had a cough, and some chest pain. She state that she encourage him to seek medical attention. She state that a couple of days later, while he was running he ''passed out'' and when he went to the doctor he was told it was asthma. Mom reported that while he was at home during Christmas, he reported to his family that he was experiencing some chest pain, and did have bumps on his face that cleared in Jan. Mom was unaware of which vaccines her son received but did remember that her son said that the needle was "funny." Mom does not recall if he had a scar on his arm. She state that he was discharged for stress related issues and complaints of chest pain. Mom is unaware of any other details regarding her son''s illness during that time only that the chest pain persisted. When questioned about his past history of asthma, she mentioned that he had it a little in childhood but has not been bothered by it since that time. She did mention that her son felt that his pain was not related to asthma. Mom was also questioned about the waiver for a medical exam upon discharge. She state that he was told that if he requested a workup, it would delay his release and that they may not even discharge him. He received his enlistment vaccines of Hep A-Hep B, Influenza, Meningococcal, MRR, Polio, and Td on 23 Nov 04 and he received his second Hep A-Hep B on 5 Jan 05. Chest pain start 11/30/2004, dyspnea (shortness of breath) start 11/30/2004. 4/3/06 Received Autopsy Report which revealed COD as chronic myocarditis.
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U1501AA / 0 UN / IM
Write-up: The Department of Health informed the HC in May 05 of the death of a medically discharged patient. The patient enlisted in Nov 04, medically discharged in Jan 05, and died on Feb 17th. The following HPI is an account of the events prior to his death as recalled by his mother during an interview in May 05. The service member a 20 year old male, who received his enlistment vaccines on 23 Nov 04. While speaking with his mom on 30 Nov he mentioned that he had a cough, and some chest pain. She state that she encourage him to seek medical attention. She state that a couple of days later, while he was running he ''passed out'' and when he went to the doctor he was told it was asthma. Mom reported that while he was at home during Christmas, he reported to his family that he was experiencing some chest pain, and did have bumps on his face that cleared in Jan. Mom was unaware of which vaccines her son received but did remember that her son said that the needle was "funny." Mom does not recall if he had a scar on his arm. She state that he was discharged for stress related issues and complaints of chest pain. Mom is unaware of any other details regarding her son''s illness during that time only that the chest pain persisted. When questioned about his past history of asthma, she mentioned that he had it a little in childhood but has not been bothered by it since that time. She did mention that her son felt that his pain was not related to asthma. Mom was also questioned about the waiver for a medical exam upon discharge. She state that he was told that if he requested a workup, it would delay his release and that they may not even discharge him. He received his enlistment vaccines of Hep A-Hep B, Influenza, Meningococcal, MRR, Polio, and Td on 23 Nov 04 and he received his second Hep A-Hep B on 5 Jan 05. Chest pain start 11/30/2004, dyspnea (shortness of breath) start 11/30/2004. 4/3/06 Received Autopsy Report which revealed COD as chronic myocarditis.
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U1501AA / 0 1 UN / IM
HEPA: HEP A (NO BRAND NAME) / UNKNOWN MANUFACTURER AHABA015AA / 1 2 UN / UN
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0706 / 0 1 UN / SC
MEN: MENINGOCOCCAL (NO BRAND NAME) / UNKNOWN MANUFACTURER UE122AA / 0 1 UN / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0781P / 0 1 UN / SC
TD: TD ADSORBED (NO BRAND NAME) / SANOFI PASTEUR 01282AA / 0 1 UN / IM
Diagnostic Lab Data: 18 Feb 05: Cardiac-normal distribution of small patent coronary arteries. The valves appear normal. The myocardium does not show any acute changes. The left ventricle measures 1.4 cm in thickness. The septum measures 1.4 cm in thickness. The aorta has youthful intima. Resp-prominent congestion and mild edema without any discrete lesion. The airways patent. The vasculature free of thromboemboli. Microscopic Exam: Heart the mural sections show rare perivascular mononuclear cells some with plasmacytoid features. The AV node section shows extensive infiltration with mononuclear cells many of which are necrotic. Lung there is edema and congestion with focal mild interstitial chronic inflammation and proliferation of pigmented alveolar macrophage macrophages. Brain and live - unremarkable. Kidney a rare Bowman capsule sclerosis is seen in the cortex. Pathologic diagnosis: Chronic myocarditis involving AV node. No lethal injuries.
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U1501AA / 1 UN / IM
HEPA: HEP A (NO BRAND NAME) / UNKNOWN MANUFACTURER AHABA015AA / 2 UN / UN
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0706 / 1 UN / SC
MEN: MENINGOCOCCAL (NO BRAND NAME) / UNKNOWN MANUFACTURER UE122AA / 1 UN / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0781P / 1 UN / SC
TD: TD ADSORBED (NO BRAND NAME) / SANOFI PASTEUR 01282AA / 1 UN / IM
Diagnostic Lab Data: 18 Feb 05: Cardiac-normal distribution of small patent coronary arteries. The valves appear normal. The myocardium does not show any acute changes. The left ventricle measures 1.4 cm in thickness. The septum measures 1.4 cm in thickness. The aorta has youthful intima. Resp-prominent congestion and mild edema without any discrete lesion. The airways patent. The vasculature free of thromboemboli. Microscopic Exam: Heart the mural sections show rare perivascular mononuclear cells some with plasmacytoid features. The AV node section shows extensive infiltration with mononuclear cells many of which are necrotic. Lung there is edema and congestion with focal mild interstitial chronic inflammation and proliferation of pigmented alveolar macrophages. Brain and live - unremarkable. Kidney a rare Bowman capsule sclerosis is seen in the cortex. Pathologic diagnosis: Chronic myocarditis involving AV node. No lethal injuries.
https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=250332&WAYBACKHISTORY=ON