Age: 30.0
Sex: M
Vaccine: RAB
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, Bile duct stenosis, Bile duct stent insertion, Bile duct stent removal
Clinical narrative: biliary stricture secondary to reactive periportal lymphadenopathy following rabies vaccination series; cholestatic hepatitis; rash; fatigue; jaundice; reactive periportal lymphadenopathy following rabies vaccination series; Introduction: Biliary strictures can be a challenging diagnosis. Work-up includes basic lab work, abdominal imaging, and even invasive procedures such as endoscopic retrograde cholangiopancreatography (ERCP). Although up to 30% of strictures are benign, the majority are malignant in the form of pancreatic adenocarcinoma and cholangiocarcinoma. As a result, a multidisciplinary approach is vital to differentiate between the 2. Case Description/Methods: A 30-year-old man with no past medical history presented with a rash, fatigue, and jaundice for 1 week. Of note, the patient was exposed to a bat in his home that had tested positive for rabies. He had subsequently completed the 3 vaccine series 5 days prior to arrival. Denied alcohol use, drug use, recent travel, new medications/supplements, or high-risk sexual behavior. On arrival, aspartate aminotransferase 165, alanine transaminase 372, total bilirubin 9.2, and direct bilirubin 6.6. Serological and infectious work-up unrevealing. Magnetic resonance cholangiopancreatography showed focal narrowing of common hepatic duct. ERCP/endoscopic ultrasound showed reactive periportal lymphadenopathy causing compression of common hepatic duct. The stricture was dilated and the patient received 2 biliary stents in left and right hepatic duct. Subsequent liver biopsy consistent with cholestatic hepatitis. Surgical pathology following stent removal negative for malignancy. Liver function tests normalized on outpatient follow-up. Discussion: The exact incidence of biliary strictures is unknown. In individuals with accompanying obstructive jaundice, the stricture should be considered malignant unless proven otherwise. Common etiologies of benign biliary strictures include iatrogenic (post-procedure), chronic pancreatitis, and primary sclerosing cholangitis. Rarely in the literature is reactive lymphadenopathy a cause of obstruction. This case highlights the importance of a thorough history and physical, as well as prompt imaging to establish a diagnosis.  Initial information received on 30-Dec-2024 via Other Health Care Professional regarding an unsolicited valid serious case issued from a literature article:   This case involves a 30-year-old male patient who experienced reactive periportal lymphadenopathy, biliary stricture secondary to reactive periportal lymphadenopathy following rabies vaccination series (bile duct stenosis) and cholestatic hepatitis while receiving vaccine Rabies Vaccine (Latency: unknown).  The patient's past medical treatment(s), vaccination(s) and family history were not provided. Patient with no past medical history.  On an unknown date, the patient was exposed to a bat in his home that had tested positive for rabies. He had subsequently completed the 3-vaccine series of Rabies Vaccine produced by unknown manufacturer lot number not reported via unknown route in unknown administration site 5 days prior to arrival. Denied alcohol use, drug use, recent travel, new medications/supplements, or high-risk sexual behavior.  On an unknown date, the patient presented with a rash, fatigue, and jaundice for 1 week. On arrival, aspartate aminotransferase 165, alanine transaminase 372, total bilirubin 9.2, and direct bilirubin 6.6. Serological and infectious work-up unrevealing. Magnetic resonance cholangiopancreatography showed focal narrowing of common hepatic duct. ERCP/endoscopic ultrasound showed reactive periportal lymphadenopathy (lymphadenopathy) causing compression of common hepatic duct. The stricture was dilated and the patient received 2 biliary stents in left and right hepatic duct. Subsequent liver biopsy consistent with cholestatic hepatitis (hepatitis cholestatic). Surgical pathology following stent removal negative for malignancy. Liver function tests normalized on outpatient follow-up.   Author stated that: Biliary strictures can be a challenging diagnosis. Work-up includes basic lab work, abdominal imaging, and even invasive procedures such as endoscopic retrograde cholangiopancreatography (ERCP). Although up to 30% of strictures are benign, the majority are malignant in the form of pancreatic adenocarcinoma and cholangiocarcinoma. As a result, a multidisciplinary approach is vital to differentiate between the 2. The exact incidence of biliary strictures is unknown. In individuals with accompanying obstructive jaundice, the stricture should be considered malignant unless proven otherwise. Common etiologies of benign biliary strictures include iatrogenic (post-procedure), chronic pancreatitis, and primary sclerosing cholangitis. Rarely in the literature is reactive lymphadenopathy a cause of obstruction. This case highlights the importance of a thorough history and physical, as well as prompt imaging to establish a diagnosis.  Seriousness criteria: medically significant for events cholestatic hepatitis and biliary stricture secondary to reactive periportal lymphadenopathy following rabies vaccination series and non-serious for reactive periportal lymphadenopathy. Action taken: not applicable Corrective treatment: stricture was dilated and the patient received 2 biliary stents in left and right hepatic duct for biliary stricture secondary to reactive periportal lymphadenopathy following rabies vaccination series; not reported for the events (reactive periportal lymphadenopathy following rabies vaccination series, cholestatic hepatitis). Outcome: Recovering / Resolving for the events Reporter's causality: Related; Sender's Comments: Sanofi company comment on dated 01-JAN-2025: This case involves a 30-year-old male patient who experienced reactive periportal lymphadenopathy, biliary stricture secondary to reactive periportal lymphadenopathy following rabies vaccination series (bile duct stenosis) and cholestatic hepatitis while receiving vaccine Rabies Vaccine. Based on the limited information received the causal role of VACCINE cannot be excluded due to compatible temporal relationship of ADR to the VACCINE. Further information regarding concurrent condition during vaccination, previous vaccination, tolerance, allergic history, laboratory investigations excluding alternative etiologies for the reported event are needed to fully assess this case. Based upon the reported information, the role of vaccine cannot be assessed completely.