Age: 2.0
Sex: M
Vaccine: FLUX
Symptoms: Epstein-Barr virus test negative, Erythema multiforme, Herpes simplex test negative, Immunoglobulin therapy, Immunology test normal
Clinical narrative: This is a serious literature case, initially received on 09-Jan-2018, from other health professional, concerns a 02-year-old, male child. It was reported that, the patient was healthy with all immunizations up to date. The vaccination history included influenza vaccination at 9, 12, and 23 months of age without incident. The patient had no known medication exposures, including acetaminophen or ibuprofen, preceding the appearance of skin lesions. On an unspecified date (3 months prior to the occurrence of the event), the patient was administered with yearly Influenza virus vaccine polyvalent (dose, route of administration, anatomical location, batch number, expiry date). On an unspecified date in 2013, after vaccination, the patient experienced flu symptoms (due to household contact). On an unspecified date in 2013 (reported as in winter), the patient had unspecified skin eruption. The patient was treated with dexamethasone, ibuprofen, famotidine, and diphenhydramine due to the suspicion of an allergic skin eruption. Over the next 2 days, skin lesions became widespread, prompting re-evaluation. On an unspecified date in 2013 (reported as 2 days later), the patient was presented with a 5-day history of fever, congestion, rhinorrhea, myalgia and a progressive pruritic facial eruption. The significant vital signs observed were, fever of 101-degree F, tachycardia and tachypnea with normal blood pressure. The skin examination revealed pink, annular, edematous papules and plaques on the face, trunk, buttocks, and extremities, many with dusky violaceous centers. Multiple tense vesicles and targetoid erythematous papules were located perianally. Rare serous vesicles were noted centrally, with negative Nikolsky and Asboe-Hansen signs. There was no skin mildly injected sclera, and dry crusted lips. There was no genital or palmoplantar involvement. The other physical examination was unremarkable. Relevant laboratory investigations showed leukocytosis (17 x 109/L) and high C-reactive protein (10/mg/L). The treatment was initiated empirically with azithromycin, acyclovir, and clindamycin was started while serologic titers and cultures (urine, skin, blood) were not taken. As fever continued, piperacillin/tazobactam was added on the second day of hospitalization. A nasopharyngeal swab was positive for influenza B and negative for mycoplasma and 18 other common respiratory pathogens according to a respiratory viral polymerase chain reaction (PCR) panel. Then, Oseltamivir therapy was initiated, and supportive care was provided. On an unspecified date, skin biopsy performed revealed necrotic keratinocytes within the epidermis and an interface dermatitis consistent with the erythema multiforme/Stevens-Johnson syndrome (EM/SJS) spectrum of inflammatory dermatoses. Immunofluorescence studies were negative for immunobullous disease. Anti-streptolysin O (ASO), mycoplasma, parvovirus, herpes simplex virus (HSV), Epstein-Barr virus (EBV), and cytomegalovirus titers; surface bacterial and viral cultures; blood culture; and urine culture was negative. Subsequently, acyclovir and antibiotics were discontinued. Despite of the supportive therapy provided, the patient's eruption rapidly progressed to involve more than 10% of his body surface area, with skin fragility and denudation which required a transfer to intensive care unit (ICU). Wound care and fluid management were continued. As the cutaneous disease progressed, intravenous immunoglobulin (IVIg) 1 g/kd/d was administered for 3 days, resulting in defervescence and skin stabilization. The patient's lesions re-epithelialized and was discharged on seventh day of hospitalization. He was well with minimal post-inflammatory hypopigmentation noted 3 months after hospital discharge. It was reported that, the patient was administered with the influenza vaccine of the following season containing both influenza lineages under close monitoring with no adverse reactions. The reporter assessed the events, vaccination failure (medically significant), Stevens-Johnson syndrome, Influenza (hospitalization and medically significant), tachypnoea, leukocytosis, tachycardia, erythema multiforme, C-reactive protein, lymphadenopathy (hospitalization). The author stated that, patient had received three prior injections of trivalent inactivated influenza vaccines at ages 9, 12, and 23 months without incident, there was concern when the patient had re-exposure to influenza B antigen in the form of vaccination, hence the causality was assessed as related.