Transcript Unusual reaction to an influenza vaccination

Unusual reaction to an
influenza vaccination
Primary Care Conference
Clinical Case Presentation
Rebecca Byers MD
April 12, 2006
Clinical Scenario
• Patient is a 50 year old woman who
presented to clinic Feb. 2004 with a
nontender, indurated-feeling left triceps
muscle.
• HPI - no recent illness. Had flu vaccine in left
deltoid Jan. 2004.
• PMH - hyperlipidemia, chronic rhinitis.
• Meds - aspirin, Niaspan, Ortho Tri-cyclen,
Allegra, Zocor.
Exam
• Afeb. VSS.
• Left upper extremity - no skin changes.
4 to 5 cm by 3 cm indurated area over
the triceps. Nontender.
• Skin exam o/w unremarkable.
• No LAD anywhere.
• Lungs, Cardiac, Abdomen - all normal.
Consults/Tests
• Ordered MRI and scheduled appt for pt
in Oncology, with concern of sarcoma.
• MRI - lesion limited to subcutaneous fat
and did not invade muscle.
• Referred to Dermatology.
• Subcutaneous biopsy - Granulomatous
Dermatitis, Sarcoidal Type.
Chest CT
• Bilateral hilar adenopathy and right
paratracheal adenopathy with no
evidence of significant lung
parenchymal involvement.
• No prior chest films available.
PFTs
•
•
•
•
FEV1 3.50 (132% predicted)
FVC 4.49 (129% predicted)
Ratio 0.78
DLCO 98%
Labs
• CBC - WBC 6.3 with nl diff, hct 44, plts
294,000.
• Creat 0.9.
• ACE level 38.
• CK 23.
• ALT 32.
Further consults
• Ophtho - No evidence of ocular sarcoid.
• Pulmonary - Confirmed diagnosis of
Stage I pulmonary sarcoid with
extrapulmonary involvement. Discussed
possible treatment (steroids,
hydroxychloroquine); decided on
watchful waiting, with recommendation
to return in 6 months for followup.
Sarcoidosis
• Systemic granulomatous disease that
primarily affects the pulmonary and
lymphatic systems.
• Diagnosis is established when clinicoradiological findings are supported by
histological evidence of noncaseating
epithelioid cell granulomas.
Etiology
• The exact cause(s) of sarcoid are
unknown, but there are 3 different lines
of evidence supporting the theory that
sarcoid occurs in genetically susceptible
hosts when exposed to specific
environmental agents.
Conclusion
• Plausible that the influenza vaccine,
administered subcutaneously, was the
environmental antigen that triggered the
patient’s local granulomatous response.
Objectives
• To illustrate a clinical case in which the
patient identified the most likely causative
event for her subsequent diagnosis.
• To describe a clinical case in need of
evidence-based criteria to help determine
cause and future treatment decisions.
• No financial disclosures.
References
• ATS guidelines: Statement on sarcoidosis.
The American Thoracic Society, Am J Respir
Crit Care Med 1999; 160:736.
• Martinetti, M, Tinelli, D, Kolek, V, et al. “The
sarcoidosis map”: A joint survey of clinical
and immunogenetic findings in two European
countries. Am J Respir Crit Care Med 1995;
152:557.