Age: 7.0
Sex: F
Vaccine: FLUX
Symptoms: Anti-aquaporin-4 antibody negative, Antibody test negative, Blindness, C-reactive protein increased, CSF test normal
Clinical narrative: Bilateral scleritis; Optic perineuritis (left greater than right); Uveitis; This literature case was received on 03-Jul-2023 and concerned a 7-year-old, female patient.  Optic perineuritis was a rare orbital inflammatory disease that typically presented with unilateral symptoms, but might be bilateral and was rare in children. Bilateral uveitis and scleritis were uncommon in children. Rarely, perineuritis, sceritis and uveitis had been reported following influenza vaccination.This conference abstract described a rare case of bilateral optic perineuritis, scleritis and uveitis in a pediatric patient following influenza vaccination.  The patient's medical history and concomitant medications were not reported.   On an unspecified date, the patient was vaccinated with influenza vaccine (brand not specified; route of administration, anatomical location, dose, and indication: not reported). The batch number was not reported.  On an unspecified date, two weeks after receiving the influenza vaccine, the patient experienced bilateral eye pain, vision loss, extreme photophobia and sleepiness.  On an unspecified date, two months after starting symptoms, the patient was presented to a medical team. At presentation she had decreased visual acuity (VA) bilaterally (right, 20/100; left, 20/80), bilateral scleral erythema, and bilateral optic disc edema. Magnetic resonance imaging (MRI) of the brain showed bilateral scleritis and optic perineuritis (left greater than right), with classic tram-track sign on axial view and donut sign on coronal view of the optic nerves. No other brain or cervical/thoracic lesions were seen. Serum antibodies to aquaporin 4, myelin oligodendrocyte glycoprotein, rheumatological work up and infectious studies were unremarkable. C-reactive protein and erythrocyte sedimentation rate were elevated. Routine cerebrospinal fluids findings were normal. The patient was treated with 2 g/kg of intravenous immunoglobulins (IVIG) followed by 30 mg/kg methylprednisolone intravenously (given insufficient response to IVIG), and oral steroid taper that was still ongoing at the time of reporting (current dose: 12.5 mg/day). Methotrexate was started due to uveitis, 25 mg once a week.   On an unspecified date, one month after treatment initiation, follow-up MRI of the brain showed a significantly improved bilateral optic per neural enhancement and scleritis.  At the time of initial reporting, the patient was recovering from the events of scleritis and optic perineuritis. Visual acuity was 20/30 bilaterally.   In conclusion, bilateral optic perineuritis, scleritis and uveitis could occur in a single pediatric patient and could potentially represent a post-vaccinal phenomenon. Timely recognition and treatment was important for visual outcomes.  The reporter assessed the events of scleritis, optic perineuritis, and uveitis to be related to influenza vaccine since it was stated that it could potentially represent a post-vaccinal phenomenon.  The events of scleritis, optic perineuritis, and uveitis were considered to be medically significant by a Physician within Risk Management Department.   Company comment: A 7-year-old, female patient was vaccinated with influenza vaccine. Two weeks after vaccination, the patient experienced bilateral eye pain, vision loss, extreme photophobia and sleepiness. Two months after symptoms onset, the patient had decreased visual acuity bilaterally, bilateral scleral erythema, and bilateral optic disc edema. Magnetic resonance imaging (MRI) of the brain showed bilateral scleritis and optic perineuritis. No other brain or cervical/thoracic lesions were seen. Serum antibodies, rheumatological work up and infectious studies were unremarkable. C-reactive protein and erythrocyte sedimentation rate were elevated. Routine cerebrospinal fluids findings were normal. The patient was treated with intravenous immunoglobulins followed by methylprednisolone and oral steroid. In addition, methotrexate was started due to uveitis. Follow-up MRI of the brain showed a significantly improved bilateral optic per neural enhancement and scleritis, a month following treatment. The patient's medical history and concomitant medications were not reported. Nevertheless, causal role of the suspect vaccine is assessed as possibly related for the events scleritis, optic perineuritis and uveitis, based on the provided information and plausible temporal relationship.; Reporter's Comments: The reporter assessed the events of scleritis, optic perineuritis, and uveitis  to be related to influenza vaccine since it was stated that it could potentially represent a post-vaccinal phenomenon; Sender's Comments: A 7-year-old, female patient was vaccinated with influenza vaccine. Two weeks after vaccination, the patient experienced bilateral eye pain, vision loss, extreme photophobia and sleepiness. Two months after symptoms onset, the patient had decreased visual acuity bilaterally, bilateral scleral erythema, and bilateral optic disc edema. Magnetic resonance imaging (MRI) of the brain showed bilateral scleritis and optic perineuritis. No other brain or cervical/thoracic lesions were seen. Serum antibodies, rheumatological work up and infectious studies were unremarkable. C-reactive protein and erythrocyte sedimentation rate were elevated. Routine cerebrospinal fluids findings were normal. The patient was treated with intravenous immunoglobulins followed by methylprednisolone and oral steroid. In addition, methotrexate was started due to uveitis. Follow-up MRI of the brain showed a significantly improved bilateral optic per neural enhancement and scleritis, a month following treatment. The patient's medical history and concomitant medications were not reported. Nevertheless, causal role of the suspect vaccine is assessed as possibly related for the events scleritis, optic perineuritis and uveitis, based on the provided information and plausible temporal relationship.