Age: 55.0
Sex: F
Vaccine: FLUX, TDAP, FLUX, TDAP
Symptoms: C-reactive protein normal, Impaired driving ability, Injected limb mobility decreased, Injection site inflammation, Injection site macule
Clinical narrative: Initial unsolicited literature report received on 18 May 2015. A 55-year-old woman presented with a 3-month history of left shoulder pain occurring less than 24 hrs after receiving an Influenza vaccination and a Tdap vaccination. She described her pain as dull/achy, 5 out of 10 (10-point scale with 10 being the worst pain) at rest, and exacerbating with shoulder manipulation, most notably with abduction. In addition, she reported persistent 3-4/10 dull pain at rest, sleep disturbances due to pain, and difficulty with lifting, carrying and driving. The patient denied prior shoulder pain, fever, redness, soft tissue swelling, interval trauma, excessive lifting, pulling or exercising. Physical exam findings were positive for left deltoid tenderness, restricted adduction, and tenderness upon passive abduction and arm elevation reflexes, strength, and sensation were intact. Serum C-reactive protein was normal. After minimal avail from multiple sessions of physical therapy and oral pain medications, a non-enhanced MRI of the left shoulder was ordered. Imaging Findings: Initial non-enhanced MRI of the left shoulder demonstrated abnormal osseous edema in the lateral humeral head and neck, and abnormal soft tissue edema in the teres minor muscle, including its myotendinous junction and humeral insertion. These post-injection findings were attributed to sequela from direct needle impact and reactive change related to the injected material. A 3-month follow-up (after an ineffective subacromial corticosteroid injection) non enhanced MRI demonstrated ongoing inflammatory disease as evidenced by new visualization of an 8-mm humeral head cortical erosion. The patient's pain persists, but at approximately 6 weeks post-injection, her pain with sleep reduced from 4/10 to 2/10. In addition, her rest pain reduced from 5/10 to 3/10 at approximately 7 weeks but with persistent mild restricted motion on physical exam. Diagnosis: Shoulder injury related to vaccine administration (SIRVA). Less likely differential considerations include focal septic arthritis, calcific tendinitis with intraosseous penetration, gout, and seronegative spondylorathropathic enthesopathy. A 55-year old female patient, whose medical history and concomitant medications were not reported, had received a dose of Influenza vaccine (batch number and expiry date, route and site of administration were not reported) and also received a dose of Tdap (batch number and expiry date, route and site of administration were not reported) on unspecified date. On unspecified, post vaccination the patient had experienced symptoms like left shoulder pain / left deltoid tenderness, pain exacerbating with shoulder manipulation, most notably with abduction / mild restricted motion / difficulty with lifting, carrying and driving, pain as dull or achy at rest / dull pain at rest, sleep disturbances due to pain. A 3-month follow-up (after an ineffective subacromial corticosteroid injection) non-enhanced MRI demonstrated ongoing inflammatory disease as evidenced by new visualization of an 8-mm humeral head cortical erosion. The patient's pain persists, but at approximately 6 weeks post-injection, her pain with sleep reduced from 4/10 to 2/10. In addition, her rest pain reduced from 5/10 to 3/10 at approximately 7 weeks but with persistent mild restricted motion on physical exam. No information about prior exposure to vaccine was provided. On unspecified, post vaccination the patient had experienced shoulder injury related to vaccine administration (SIRVA). Prolonged shoulder pain occurring acutely after vaccination should prompt physicians to incorporate SIRVA in their differential of possible causes. In addition, vaccine administrators in healthcare facilities nationwide should be educated on the potential risks (physician and economic) of over-penetration associated with the current CDC's needle length recommendations. Laboratory investigations and subacromial corticosteroid injection was given as corrective treatment for (SIRVA). At the time of this report, the patient outcome was recovering. Documents held by sender: none.