Sex: F
Vaccine: FLUX
Symptoms: Anti-cyclic citrullinated peptide antibody positive, Antinuclear antibody negative, Antinuclear antibody positive, Arthralgia, C-reactive protein increased
Clinical narrative: This case was reported in a literature article and described the occurrence of rheumatoid arthritis in a 33-year-old female patient who received Influenza vaccine unspecified. Co-suspect products included Swine Influenza Vaccine. In October 2009, the patient received Influenza vaccine unspecified. In November 2009, the patient started Swine Influenza Vaccine at an unknown dose and frequency. On an unknown date, 7 days after receiving Influenza vaccine unspecified, the patient experienced rheumatoid arthritis (serious criteria GSK medically significant), joint pain and pain in hand. The patient was treated with methotrexate, Calcium plus Vitamin D, folic acid, prednisone and golimumab. On an unknown date, the outcome of the rheumatoid arthritis and joint pain were recovering/resolving and the outcome of the pain in hand was recovered/resolved. The reporter considered the rheumatoid arthritis, joint pain and pain in hand to be possibly related to Influenza vaccine unspecified. Additional information was provided. This case was reported in a literature article and described the occurrence of rheumatoid arthritis (RA) in a 33-year-old female who was vaccinated with unspecified seasonal flu vaccine and unspecified H1N1 (swine influenza) vaccine (manufacturer unknown for both). The patient had no significant past medical history. No information on patient's family history or concomitant medication or concurrent condition was provided. On an unspecified date in October 2009, the patient received unspecified seasonal flu vaccine (administration site and route; dosages unknown; batch number not provided). The age of vaccination was not provided. On an unspecified date, 1 week after vaccination, the patient noted some joint pain and aches in hands, wrists, and knees, which resolved within a few days and the patient became asymptomatic. A month later, the patient received unspecified H1N1 (swine influenza) vaccine (administration site and route; dosages unknown; batch number not provided). A week after, in November 2009, the patient started experiencing joint pain, swelling, and stiffness in hand, wrist, elbow, shoulder, and knee joints. In May 2010, the patient was referred to the rheumatology clinic by her primary care physician for having pain and swelling in multiple joints since November 2009. The patient complained of significant morning stiffness that lasted for more than 1 hour. On physical examination, the patient had bilateral synovitis in 4th, 5th metacarpophalangeal (MCP), 2nd, 3rd proximal interphalangeal (PIP) joints, with prominent left ulnar styloid. The patient fulfilled most of the criteria for classification of RA based on Rheumatology guidelines. Laboratory findings initially included an erythrocyte sedimentation rate (ESR) of 24 mm/hr, rheumatoid factor (RF) of 26 IU/mL, C-reactive protein (CRP) of 1.3 mg/dL, cyclic citrullinated peptide (CCP) IgG of 212 (normal range not provided). Basic chemistry, liver function tests, haemoglobin, and complement levels were essentially within normal limits (values and normal range not provided). Serological tests were positive for antinuclear antibody (ANA), RF, anticyclic citrullinated peptide (anti-CCP) and negative for SSA, SSB, hepatitis C virus, parvovirus B19 and being immunized for hepatitis B. Radiological findings were negative for any joint effusion or destruction. On initial presentation to her primary care physician (PCP), the patient was given a 10-day course of prednisone 40 mg daily, which partially helped with symptoms in the beginning with eventual relapse of symptoms. Later, the patient was started on methotrexate 7.5 mg weekly along with a short duration (3 weeks) of low-dose prednisone with daily folic acid and calcium/vitamin D supplementation. About 2 months later, during the follow-up visit, her disease activity score (DAS) were 4.83 and number of tender joints was 7 and number of swollen joints were 5, with significant improvement in morning stiffness which lasted for 5-10 minutes. However, her pain was controlled only while she was on steroid therapy for 3 weeks and had returned thereafter. Later she was switched to golimumab [tumour necrosis factor (TNF)-a inhibitor] 50 mg once monthly subcutaneously. Her methotrexate dose was also increased to 12.5 mg weekly. At her 3rd visit, the symptoms were much improved and her ESR and CRP were also within normal limits. The authors commented, "there was a temporal relationship between swine influenza vaccination and onset of RA. There might also be a synergetic effect of seasonal flu and swine flu vaccines in our study. This patient could be genetically susceptible because of her race". The authors concluded "a causal relationship has not been confirmed between swine-flu vaccine and onset of RA, but there is a temporal connection between the two based on our case report".