Age: 25.0
Sex: F
Vaccine: FLUX(H1N1)
Symptoms: Blood culture negative, Bone marrow oedema, C-reactive protein increased, Injection site pain, Joint range of motion measurement
Clinical narrative: This serious literature report (initial receipt 09-Jul-2015) concerns a 25 year-old female patient who was a dermatology nurse. On an unspecified date, the patient received H1N1 (manufacturer and batch number not provided). On an unspecified date, three weeks following the vaccine administration, the patient experienced left shoulder pain. The pain was persistent and moderate. She denied any other injury, any skin reaction at the site of the injection, fever or chills. The pain is significantly worsened after moving a desk several days prior to presentation. She could not lift her arm beyond the height of her shoulder without severe pain. She commented that "?" was the most painful shot "?" ever gotten and that the injection was given using a 1.5 inch needle, which penetrated all the way to the hub when the injection was given. On physical examination, the patient was afebrile and well-appearing. Her neck showed full AROM (active range of motion) of the left shoulder with approximately 90 degrees abduction, 60 degrees internal rotation, 90 degrees external rotation. In comparison, her right arm demonstrated 130 degrees abduction, 80 degrees internal rotation, and 100 degrees external rotation. She had positive "?" and "?" supraspinatus testing, positive Speed's (?) test, positive Neer's (?) sign, and negative cross-arm test. There was exquisite tenderness to palpation at the lateral aspect of the proximal humerus, consistent with the reported site of the injection. There was no overlying erythema or edema or at the injection site. The broad differential diagnosis included subacromial bursitis, rotator cuff tendinopathy, biceps tendinopathy, inflammatory periosteal reaction (secondary to the injection), humeral fracture, osteomyelitis, and tumor. According to the laboratory studies, her CBC (complete blood count) showed elevated WBC (white blood cell) of 14.2 with 8.7 PMN, otherwise normal. The sedimentation rate was normal, CRP (C-reactive protein) was elevated at 13.8, and blood cultures showed no growth. Other studies included an AP and outlet x-ray images of the left shoulder which were normal. An MRI (magnetic resonance imaging) of the left shoulder was obtained due to severe pain. This showed localized non-specific humeral edema of the greater tuberosity with no internal derangement or tearing/inflammation of the rotator cuff musculature. There was a concern for possible osteomyelitis and was not recommended to start on antibiotics since the patient was afebrile and blood cultures were negative. She was diagnosed with periosteal reaction secondary to influenza vaccination. Treatment included meloxicam and tramadol for pain control, and advised to rest her arm when possible. She was instructed to notify the office if she developed a fever or any signs of systemic infection. The patient's shoulder pain gradually improved. She was re-evaluated five months post-injection and still had mild pain at the injection site. Repeat MRI was obtained at the time which showed decreased periosteal reaction compared with prior imaging. The outcome was unknown (recovering for shoulder pain).