Age: 43.0
Sex: M
Vaccine: HEP
Symptoms: Treponema test negative, Uveitis, Visual acuity reduced, Visual impairment, Vitiligo
Clinical narrative: This case was reported in a literature article and described the occurrence of Vogt-Koyanagi-Harada syndrome in a 43-year-old male patient who received Hepatitis B vaccine for prophylaxis. Concurrent medical conditions included type II diabetes mellitus. On an unknown date, the patient received the 1st dose of Hepatitis B vaccine. On an unknown date, 3 days after receiving Hepatitis B vaccine, the patient experienced Vogt-Koyanagi-Harada syndrome (serious criteria GSK medically significant), anterior uveitis (serious criteria GSK medically significant), disc edema in ocular fundus (serious criteria GSK medically significant), blind right eye (serious criteria GSK medically significant), subretinal fluid (serious criteria GSK medically significant), panuveitis (serious criteria GSK medically significant), choroiditis (serious criteria GSK medically significant), choroidal neovascularization (serious criteria GSK medically significant), retinal detachment (serious criteria GSK medically significant), vision decreased, photophobia, eye red, chorioretinal disorder, tinnitus, headache, vitiligo, lymphadenopathy mediastinal, eye inflammation, lung nodule and hypoperfusion. The patient was treated with prednisolone, prednisone, cyclopentolate, methotrexate, bevacizumab and corticosteroid NOS (Trade Name Unknown). On an unknown date, the outcome of the Vogt-Koyanagi-Harada syndrome, anterior uveitis, disc edema in ocular fundus, blind right eye, subretinal fluid, panuveitis, choroiditis, retinal detachment, vision decreased, photophobia, eye red, chorioretinal disorder, tinnitus, headache, vitiligo, lymphadenopathy mediastinal, eye inflammation, lung nodule and hypoperfusion were unknown and the outcome of the choroidal neovascularization was recovered/resolved. The reporter considered the Vogt-Koyanagi-Harada syndrome, anterior uveitis, disc edema in ocular fundus, blind right eye, subretinal fluid, panuveitis, choroiditis, choroidal neovascularization, retinal detachment, vision decreased, photophobia, eye red, chorioretinal disorder, tinnitus, headache, vitiligo, lymphadenopathy mediastinal, lung nodule and hypoperfusion to be related to Hepatitis B vaccine. It was unknown if the reporter considered the eye inflammation to be related to Hepatitis B vaccine. Additional information was provided. This case was reported in a literature article and described the occurrence of Vogt-Koyanagi-Harada (VKH) disease in 43-year-old male patient was vaccinated with unspecified hepatitis B virus vaccine (manufacturer unknown) for prophylaxis. The patient was a male with type II diabetes mellitus. The patient had no history of penetrating ocular trauma or surgery. No information on family or concomitant medication was provided. On an unspecified date, the patient received 1st dose of single-antigen hepatitis B vaccine (administration route and site unspecified, batch number not provided). The age of vaccination was not provided. On an unspecified date, 3 days after vaccination, the patient developed decreased vision, photophobia, and redness in both. He was initially diagnosed with anterior uveitis by an outside specialist and treated with topical prednisolone acetate 1%. 1 week later, he developed sudden loss of vision in the right eye and was referred to our service for further management. On presentation, best corrected visual acuity was 20/800 in the right eye and 20/40 in the left eye with intraocular pressures of 18 and 12 mmHg, respectively. Anterior segment exam was notable for trace cell with pigment on the anterior lens capsule in the right eye and trace cell with scattered posterior synechiae and pigment on the anterior lens capsule in the left eye. There were trace cells in the anterior vitreous of both eyes without vitreous haze. Funduscopic examination showed disc oedema with numerous deep creamy-white lesions in the posterior pole of both eyes. Enhanced depth imaging (EDI) with spectral domain optical coherence tomography (OCT) demonstrated marked choroidal thickening that was more prominent in the right eye with choroidal undulation and sub-retinal fluid accumulation. The patient also presented with serous retinal detachment. OCT also showed sub-retinal setae with associated cystic cavities. Wide-field fluorescein angiography (FA) demonstrated early hypofluorescence with late hyperfluorescence of the placoid lesions, along with several pinpoint leaks in the posterior pole. Indocyanine green angiography (ICG) of right eye showed choroidal hypoperfusion with hypocyanescent lesions in early and very late phases. Review of systems was unremarkable, and diagnostic work-up, including interferon gamma release assay (QuantiFERON TB-gold), angiotensin-converting enzyme, Treponemal IgG, bartonella serologies, HLA testing, and chest x-ray, were all unremarkable. Clinical and laboratory investigation was also negative for other ocular disease entities. The patient was treated for non-infectious pan uveitis with choroiditis with a daily dose of 100 mg of oral prednisone (1 mg/kg body weight), topical prednisolone acetate 1%, and cyclopentolate 1%. Vision and retinal anatomy improved dramatically within days of initiating systemic corticosteroid treatment. 2 months after initial presentation, visual acuity had improved to 20/30 in both eyes with normalization of retinal anatomy on OCT. The patient was advised against completing the HBV vaccine series. The patient was then lost to follow-up and re-presented 5 months later due to recurrent symptoms. In the interim, he reported two flares during which he self-treated with oral and topical steroids for 3 days each with resolution. Review of systems was now significant for tinnitus and headaches. On re-evaluation of family history, the patient reported paternal ancestors. Inspection of the skin showed hypopigmented areas on the chin consistent with vitiligo. Best corrected visual acuity was 20/25 in both eyes. Funduscopic examination revealed recurrent disc edema bilaterally with new deep creamy-white lesions in the posterior pole of both eyes. A peri-papillary choroidal neovascular membrane (CNVM) was present in the right eye. Computed tomography of the chest showed mediastinal lymphadenopathy and an 8 mm lung nodule. A lumber puncture was normal without cerebrospinal fluid (CSF) pleocytosis or malignant cells. A clinical diagnosis of VKH was made and intraocular inflammation was controlled with oral corticosteroids followed by methotrexate for long-term disease control. The CNVM resolved with one treatment of intravitreal bevacizumab (1.25 mg/0.05 cc). The patient was referred to pulmonology and evaluation was not consistent with sarcoidosis. The outcome of the event was not reported. The author considered the event of Vogt-Koyanagi-Harada (VKH) disease related to unspecified hepatitis B vaccine. The author stated, "This is a unique case of VKH disease associated with hepatitis B vaccination. While the underlying aetiology remains unclear, VKH disease can be associated with a viral prodrome suggesting an infectious trigger that alters the immune response. Although it is difficult to determine causality, our case raises the possibility of hepatitis B vaccination triggering VKH disease in a susceptible individual. The benefits of vaccination clearly outweigh the potential adverse effects; however, ophthalmologists should be aware of the potential for vaccine-associated uveitis. If the uveitis is felt related to the vaccine, then we recommend a discussion between the patient and care team regarding continuation of the vaccine series."  Lab Comments: Laboratory tests were performed on unspecified date. Best corrected visual acuity was 20/800 in the right eye and 20/40 in the left eye with intraocular pressures of 18 and 12 mmHg, respectively. Anterior segment exam was notable for trace cell with pigment on the anterior lens capsule in the right eye and trace cell with scattered posterior synechiae and pigment on the anterior lens capsule in the left eye. There were trace cells in the anterior vitreous of both eyes without vitreous haze. Funduscopic examination showed disc oedema with numerous deep creamy-white lesions in the posterior pole of both eyes. Enhanced depth imaging (EDI) with spectral domain optical coherence tomography (OCT) demonstrated marked choroidal thickening that was more prominent in the right eye with choroidal undulation and sub-retinal fluid accumulation.OCT also showed sub-retinal setae with associated cystic cavities. Wide-field fluorescein angiography (FA) demonstrated early hypofluorescence with late hyperfluorescence of the placoid lesions, along with several pinpoint leaks in the posterior pole. Indocyanine green angiography (ICG) of right eye showed choroidal hypoperfusion with hypocyanescent lesions in early and very late phases. 2 months after initial presentation, visual acuity had improved to 20/30 in both eyes with normalization of retinal anatomy on OCT. Inspection of the skin showed hypopigmented areas on the chin consistent with vitiligo. Best corrected visual acuity was 20/25 in both eyes. Funduscopic examination revealed recurrent disc edema bilaterally with new deep creamy-white lesions in the posterior pole of both eyes. Computed tomography of the chest showed mediastinal lymphadenopathy and an 8 mm lung nodule. A lumber puncture was normal without cerebrospinal fluid (CSF) pleocytosis or malignant cells.