Age: 36.0
Sex: F
Vaccine: FLUX, FLUX
Symptoms: Anal sphincter atony, CSF glucose normal, CSF myelin basic protein normal, CSF protein increased, CSF red blood cell count positive
Clinical narrative: Case number PHHY2016US033934, is an initial literature case report received on 09 Mar 2016. The author discussed acute transverse myelitis (ATM) after influenza vaccination: magnetic resonance imaging findings. This report refers to a 36-year-old female patient. Medical history was not reported. Concomitant medication was not reported. The patient was vaccinated with influenza vaccine (manufacturer and batch number: not reported) at a dose of 0.5 ml on an unknown date and the vaccination was well tolerated by the patient. On an unknown date after vaccination, the patient presented to the medical center with a one week history of progressive leg weakness, numbness below the chest, and urinary retention. Neurological examination revealed mild to moderate weakness and hyperreflexia of the lower extremities, a discrete sensory deficit below the T-3 level and a decrease in rectal tone. Conventional spin-echo MRI of the cervical and rostral thoracic spine (General Electric 1.5-T Signal scanner) at admission revealed mild diffuse fusiform enlargement of the spinal cord extending from C-3 to the visualized upper thoracic levels, best appreciated on T1-weighted images. The same areas showed confluent intramedullary lesions containing increased T2 signal. After administration of intravenous contrast (gadopentetate dimeglumine) no abnormal enhancement was noted. In addition, MRI of the brain both with and without contrast material was unremarkable. The cerebrospinal fluid contained 84 white blood cells (90% lymphocytes and 10% monocytes), 3 erythrocytes a total protein concentration of 96 mg/dl and a normal glucose level, myelin basic protein was elevated (6 ng/ml). An extensive laboratory evaluation for an alternative underlying cause was unrevealing. Intravenous methylprednisolone therapy (1 gm/day for 5 days) led to a marked recovery by two weeks. At a routine outpatient visit 6 months later the patient reported only minimal bowel incontinence and occasional exercise induced leg paresthesias. Results of a neurological examination were normal except for trace weakness in the left quadriceps and pin induced paresthesias of the lower extremities. One year later, the patient demonstrated a complete recovery with no incontinence or paresthesias; the neurological examination was completely normal. A repeat MRI examination was not performed. The patient developed symptoms of myelopathy four weeks after vaccination. No antecedent or intercurrent causes were found. The author stated that association of ATM following the influenza vaccination does not prove cause and effect. However, because no other known causes of ATM were identified a post-vaccination syndrome was diagnosed by exclusion. The author concluded that this patient with influenza vaccination-associated ATM, MRI showed spinal cord expansion and increased intramedullary T2 signal lesions without enhancement. Although the disease presented clinically as a discrete myelopathy MRI showed that it was diffuse and extended over several spinal levels rostral to the clinical deficits. These MRI findings are nonspecific and are similar to those previously reported in idiopathic, parainfectious, and collagen vascular disease associated, and hepatitis vaccination associated ATM. Seriousness of the events was not reported. Seriousness of the event myelitis transverse was upgraded based on Novartis Important Medical Events list.