Age: 64.0
Sex: M
Vaccine: FLU4
Symptoms: Alanine aminotransferase normal, Anti-cyclic citrullinated peptide antibody negative, Antinuclear antibody negative, Arthralgia, Aspartate aminotransferase normal
Clinical narrative: Reason for Consultation: arthralgia after influenza vaccine. HISTORY OF PRESENT ILLNESS: Pt is a 64 year old male with gout and hypertension who received the influenza vaccine on 10/16/2017. He reported subjective fever later in the evening, then onset of generalized arthralgias involving left shoulder, wrists, knees and ankles. A few days later he noticed swelling and redness of bilateral wrists. This was also associated with mild weakness especially the first 3 days, but this has since improved. No headaches. He did not develop a rash around site of injection or other rash, hives, oral ulcers or mucosal lesions. He was given a 16 day course of prednisone and reported minimal decrease in joint pain joint swelling. No new medications have been prescribed. Those that he is currently taking, he has been taking for several years. He did travel in August, but felt well during and after he returned from his trip. He has never had these symptoms after influenza vaccines in the past. After the first course of prednisone, his symptoms improved but he still did not feel 100% so he returned for re-evaluation. Serum sickness was suspected and thus he was started on another tapering course of prednisone on 11/2/2017. Despite steroid therapy, he continues to have swelling and redness of the dorsal aspect of right hand/wrist and also swelling of the left 3rd and 4th IP joints. He has a history of gout but has not had a gouty flare in a while. He takes allopurinol 300 mg daily. He does miss a dose of his allopurinol about once a week. In the past he has had gout flares in the knees and ankles. While he was on his trip he did not take his allopurinol, but then resumed therapy after he returned in September. Last uric acid was 9.7 mg/dL. on 9/27/2017 (repeat uric acid was 5.4mg/dL on 11/10/2017). ASSESSMENT/PLAN: SERUM SICKNESS, SUBSEQ GOUT 64 year old male who developed fever, initially arthralgias and then joint swelling in wrists with onset of symptoms the evening after he received an influenza vaccine. He has had the flu vaccine yearly but has never had a reaction from the vaccine previously. No rash reported. Onset of symptoms right after injection seems atypical in this situation, but a more acute presentation is possible in those who have been exposed to the same agent previously. Thus he could certainly have serum sickness or more likely a serum sickness like reaction to the influenza vaccine. There are case reports of serum sickness after influenza vaccination described in the literature. Differential diagnosis also include severe gouty flare, inflammatory polyarthritis. He was off therapy for one month prior and then resumed therapy and this may have led to a gout flare. But unusual for a flare to persist this long and not respond to prednisone burst. Will continue to follow clinically to assess for persistent synovitis. Labs reviewed, no new neutropenia, thrombocytopenia or eosiniophilia, no rise in creatinine and UA without proteinuria. Complements can be low in serum sickness, though his were not decreased. As he remains symptomatic, will increase prednisone dose to 0.5 mg/kg/day and then re-evaluate symptoms in 4-6 weeks, sooner if needed.