Sex: M
Vaccine: FLUX
Symptoms: Conjunctivitis, Cough, Culture positive, Enterovirus test negative, Haemophilus infection
Clinical narrative: This case was reported in a literature article and described the occurrence of tracheobronchitis in a 76-year-old male patient who received influenza virus vaccine for prophylaxis. The patient's past medical history included squamous cell carcinoma of the hypopharynx, intensity modulated radiation therapy (treatment for hypopharyngeal squamous cell carcinoma at the age of 64 years), laryngectomy (at the age of 66 years, the patient had a recurrence of cancer and underwent laryngectomy) and diverticulitis. Previously administered products included pneumococcal polysaccharide vaccine (At the age of 74 years, the patient received a PPSV23). Concurrent medical conditions included hypertension paroxysmal and migraine. On an unknown date, the patient received influenza virus vaccine unspecified season at an unknown dose. On an unknown date, 91 days after receiving influenza virus vaccine unspecified season, the patient experienced tracheobronchitis (serious criteria GSK medically significant and other: Serious per reporter), hemophilus influenza infection (serious criteria GSK medically significant and other: Serious per reporter), respiratory distress (serious criteria GSK medically significant), fever, sputum increased, purulent conjunctivitis, cough, rhonchi, mucosal dryness and tachycardia. The patient was treated with levofloxacin, ciprofloxacin, Acetaminophen, Guaifenesin and clonidine. On an unknown date, the outcome of the tracheobronchitis, hemophilus influenza infection, respiratory distress, fever, sputum increased, purulent conjunctivitis, cough, rhonchi, mucosal dryness and tachycardia were recovered/resolved. It was unknown if the reporter considered the tracheobronchitis, hemophilus influenza infection, respiratory distress, fever, sputum increased, purulent conjunctivitis, cough, rhonchi, mucosal dryness and tachycardia to be related to influenza virus vaccine unspecified season. Additional information was provided. This case was reported in a literature article and described the occurrence of bacterial tracheobronchitis due to non-typeable Haemophilus influenzae in a 76-year-old male who was vaccinated with unspecified influenza virus vaccine (manufacturer unknown) for prophylaxis. The patient was a man. The patient had a past medical history of hypopharyngeal squamous cell carcinoma which was treated with intensity-modulated radiotherapy (IMRT) at the age of 64 years. 2 years later, the patient had a recurrence of cancer and underwent laryngectomy. Since then the patient had no signs of tumour recurrence. The patient also suffered from paroxysmal hypertension, diverticulitis, and migraines. At the age of 74 years, the patient received a PPSV23. No information on patient's family history or concomitant medication was provided. On an unspecified date, the patient had received unspecified current influenza virus vaccine (administration route and site unspecified, dosage unknown; batch number not provided). The age of vaccination was not provided. On an unspecified date, at the age of 76-years, 3 months after vaccination, the patient was presented with fever (38.9 degree C; 102.0 degree F), increased sputum production, and purulent conjunctivitis. These symptoms emerged gradually over a period of 48 hours. The patient noted increasing difficulty in coughing out his sputum that became brownish and viscous. The symptoms started a day after a very cold weather spell with temperatures of -7 to -1 degree C (19-31 degree F). The patient had been wearing a heat and moisture exchanger (HME) filter that covered stoma and patient spoke through a tracheoesophageal voice prosthesis. The patient had to remove HME on several occasions for extended periods of time to enable him to breathe when patient walked outside the home. The patient was in mild respiratory distress especially when coughing. The patient had coughing spells and expectorated green-brown dry and viscous sputum. The patient's physical examination revealed bilateral purulent conjunctivitis and auscultation of lungs revealed coarse rhonchi and no crepitations. No lymphadenopathy was noted. The results of the rest of the physical and neurological examinations were within normal limits. The patient's chest X-ray was normal. The patient's sputum and conjunctival culture grew revealed heavy growth of beta-lactamase-producing non-typeable Haemophilus influenzae (NTHi) that was susceptible to levofloxacin and amoxicillin- clavulanate. The polymerase chain reaction (PCR) test did not detect 14 viruses (adenovirus, coronavirus HKU1, coronavirus NL63, coronavirus 229E, coronavirus OC43, human rhinovirus/enterovirus, human metapneumovirus, influenza A, influenza B, parainfluenza virus 1, parainfluenza virus 2, parainfluenza virus 3, para-influenza virus 4, respiratory syncytial virus) and four bacteria (Bordetella pertussis, Bordetella parapertussis, Chlamydophila pneumoniae, Mycoplasma pneumoniae). The patient was treated with orally administered levofloxacin 500 mg/day, ciprofloxacin eye drops, acetaminophen and guaifenesin. Humidification of patient's trachea and the airway was maintained by repeated insertions of 3-5 cc respiratory saline into the stoma at least once an hour and by breathing humidified air. The main challenge was to maintain a patent airway as the mucus of the patient was very dry and viscous and tended to stick to the walls of patient's trachea and the stoma. The mucus had to be repeatedly expectorated by vigorous coughing and by manual removal from the upper part of patient's trachea and stoma. The patient experienced repeated episodes of sustained elevated blood pressure (up to 210/110) and tachycardia (112/minute). This was managed by administration of clonidine 0.1 mg as needed (1-2/day). 48 hours after antimicrobial therapy the patient's fever started to decline. The conjunctivitis improved within 36 hours. The sputum production declined and became less viscous over time but persisted for 5 days. Antimicrobial therapy was discontinued after 7 days. The patient's condition improved and had a complete recovery in 7 days. The patient was seen in the clinic every 2 months and showed no recurrence of infection for the following 8 months. The patient had received vaccination for Haemophilus. influenzae B and Prevnar 13 4 weeks after recovery. This case has been considered serious per reporter. The author did not comment on relationship between the event of bacterial tracheobronchitis and unspecified influenza virus vaccine. However, the author stated "This case report described the occurrence of a serious bacterial tracheobronchitis due to Haemophilus influenzae in a laryngectomee. The exposure of our patient to cold air without an HME most likely compromised his airway and led to the development of the infection. The author concluded "Laryngectomees are at a higher risk of developing lower respiratory tract infections especially in the winter and when not wearing an HME. Maintaining the patency of the airway is of utmost importance as the mucus can be very dry and viscous and can stick to the walls of the trachea and the stoma. The risk of acquiring these infections can be reduced by: getting vaccinated for respiratory pathogens that include Streptococcus pneumoniae, Haemophilus influenzae, and the influenza viruses; washing hands before any stoma care; wearing an HME at all times; maintaining adequate respiratory tract humidification; and avoiding hypothermia or inhaling cold air". Lab Comments: Lab tests were performed on unspecified dates. The patient's physical examination revealed bilateral purulent conjunctivitis and auscultation of lungs revealed coarse rhonchi and no crepitations. No lymphadenopathy was noted. The results of the rest of the physical and neurological examinations were within normal limits. The patient's sputum and conjunctival culture grew revealed heavy growth of beta-lactamase-producing nontypeable Haemophilus influenzae (NTHi) that was susceptible to levofloxacin and amoxicillin- clavulanate. The polymerase chain reaction (PCR) test did not detect 14 viruses (coronavirus HKU1, coronavirus NL63, coronavirus 229E, coronavirus OC43, parainfluenza virus 1, parainfluenza virus 2, parainfluenza virus 3, para-influenza virus 4) and four bacteria (Bordetella pertussis, Bordetella parapertussis, Chlamydophila pneumoniae, Mycoplasma pneumoniae). The patient experienced repeated episodes of sustained elevated blood pressure (up to 210/110) and tachycardia (112/minute).