Age: 64.0
Sex: M
Vaccine: FLUX, FLUX, FLUX, FLU3
Symptoms: Alanine aminotransferase normal, Aspartate aminotransferase normal, Blood albumin decreased, Blood bilirubin normal, Blood product transfusion
Clinical narrative: This case was reported in a literature article and described the occurrence of hemorrhagic cerebral infarction in a 64-year-old male subject who was vaccinated with influenza virus vaccine (influenza vaccine, manufacturer unspecified). Concurrent medical conditions included atrial fibrillation, chronic obstructive pulmonary disease, depression, diabetes mellitus (type2), gastroesophageal reflux, hypercholesterolemia and hypertension. Concurrent medications included Warfarin 5 mg every other day alternating with 2,5 mg, Celecoxib 200 mg as needed for pain, ipratropium/albuterol inhaler 2 puffs twice daily, diltiazem 120 mg twice daily, metformin 500 mg twice daily, hydrochlorothiazide/losartan 25 mg/100 mg daily, escitalopram 20 mg daily, lansoprazole 30 mg daily, propranolol 40 mg twice daily, and ezetimibe/simvastatin 10 mg/40 mg daily. All medication regimens were unchanged for at least 6 months. None of his medications was altered. The patient had been seen in the clinic 5 weeks prior to presentation. At the time, his INR was 2,0 and he received unspecified dose of Influenza vaccine (unknown route, unknown injection site). Lot number was not available. 5 weeks after vaccination with Influenza vaccine, the subject was hospitalized after becoming unresponsive at home. At the admission, the patient had been unresponsive for approximately 1 hour. The patient was experiencing rectal bleeding for the previous 2 days. The initial international normalized ratio (INR) was greater than 15; INR values over the previous 6 months were relatively stable. Relevant test were performed and showed the following results: Hemoglobin: 8,3 g/dL (normal range 14-18); Hematocrit: 24% (normal range 42-52); Platelet count: 412 x 10^3 /uL (normal range 150-430); low serum albumin: 3,1 g/dL (normal range 3,5-5,0); total bilirubin: 0,8 mg/dL (normal range 0,2-1,0); aspartate aminotransferase: 16 IU/L (normal range 10-42); alanine aminotransferase:12 IU/L (normal range 10-40); blood pressure: 166/60 mm Hg, heart rate: 62 beats/min; respiration rate:16 breaths/min; temperature was not documented. A non-contrast computed tomography scan of the head revealed a large parenchymal hemorrhagic infarction involving the left temporal, parietal, and occipital lobes. The radiologist noted a significant mass effect including 12mm rightward midline shift and impending uncal herniation. The subject was treated in the emergency department with Nitroglycerin infusion to maintain systolic blood pressure in the range of 140-160 mm Hg as well as the infusion of 4 units of fresh frozen plasma and 10 mg of vitamin K. Following a neurosurgery evaluation, it was determined that nothing meaningful could be done to alter the patient's outcome positively. Comfort measures were implemented and the patient died approximately 17 hours after admission. The author considered the events were possibly related to the interaction between Warfarin and vaccination with Influenza vaccine.