Age: 22.0
Sex: F
Vaccine: HEP
Symptoms: Gamma-glutamyltransferase increased, HIV test negative, Hepatitis A antibody positive, Hepatitis B DNA assay positive, Hepatitis B antibody negative
Clinical narrative: This case was reported in a literature article and described the occurrence of vaccination failure in a 22-year-old female patient who received Hepatitis B vaccine. The patient's past medical history included tattoo. Previously administered products included hepatitis A vaccine (prior to travel 4 months before) and yellow fever vaccine (prior to travel 4 months before). Concurrent medical conditions included alcohol use (200ml vodka per week). On an unknown date, the patient received Hepatitis B vaccine at an unknown dose. On an unknown date, several years after receiving Hepatitis B vaccine, the patient experienced vaccination failure (serious criteria hospitalization and GSK medically significant), acute hepatitis B (serious criteria hospitalization and GSK medically significant), fatigue (serious criteria hospitalization), nausea (serious criteria hospitalization), abdominal pain (serious criteria hospitalization), urine discoloration (serious criteria hospitalization), oral intake reduced (serious criteria hospitalization), vomiting (serious criteria hospitalization), feeling hot (serious criteria hospitalization), scleral icterus (serious criteria hospitalization) and liver tenderness (serious criteria hospitalization). On an unknown date, the outcome of the vaccination failure, acute hepatitis B, fatigue, nausea, abdominal pain, urine discoloration, oral intake reduced, vomiting, feeling hot, scleral icterus and liver tenderness were recovered/resolved. The reporter considered the vaccination failure to be related to Hepatitis B vaccine. It was unknown if the reporter considered the acute hepatitis B, fatigue, nausea, abdominal pain, urine discoloration, oral intake reduced, vomiting, feeling hot, scleral icterus and liver tenderness to be related to Hepatitis B vaccine. Additional information was provided: This case was reported in a literature article and described the occurrence of possible vaccination failure in 22-year-old female who was vaccinated with unspecified hepatitis B vaccine (manufacturer unknown). Social history was significant for recent unlicensed tattoos, unprotected sex with a male partner and weekly alcohol use of 200mL vodka. Four months prior traveling, the patient was vaccinated to unspecified hepatitis A and unspecified yellow fever. No information on patient's family history or concurrent conditions was provided. No information on patient's concomitant medication was provided. On an unspecified date in childhood, the patient received unspecified hepatitis B vaccine (administration route and site unspecified; dosages unknown; batch number not provided). On an unspecified date, an unknown period after vaccination with unspecified hepatitis B vaccine, the patient presented with 2 weeks of fatigue, nausea, and abdominal pain. The patient reported generalized fatigue, dark urine, decreased oral intake, nausea and vomiting, subjective fevers, and intermittent abdominal pain. Examination revealed scleral icterus and right upper quadrant tenderness without hepatomegaly. The patient denied recent acetaminophen or intravenous drug use. The patient's initial laboratory evaluation revealed aspartate transaminase of 1273, alanine aminotransferase of 1968, total bilirubin of 8.4 mg/dL and direct bilirubin of 6.0 mg/dL. Alkaline phosphatase was normal and gamma glutamyl transpeptidase was elevated at 81 units/L. A right upper quadrant ultrasound revealed no evidence of obstruction with normal echogenicity of the liver. Subsequently, the patient was admitted for evaluation of her transaminitis. It was reported that patient's human immune deficiency syndrome and hepatitis C virus serologies were negative. Hepatitis A IgG was positive but IgM negative. Hepatitis B surface antigen was positive, surface antibody was indeterminate and core IgM was positive. Her Hepatitis B DNA copies were at 3.37 IU/mL. Hepatitis B virus E antigen was positive with a negative E antibody. Autoimmune disease markers were unremarkable. The patient was diagnosed with acute hepatitis B infection. This case was considered serious due to hospitalisation. The patient was started on supportive care and counseling about risk behaviours. The patient was recovered without complication. The authors comment on the relationship was "those vaccinated as children grow into adulthood and engage in high risk behaviours, breakthrough infections may become more common". The authors stated that "Acute hepatitis B infection is diagnosed through serologic markers of infection. Hepatitis B surface antigen is the hallmark of infection and the presence of IgM antibody to hepatitis B core antigen indicates acute infection. Over time, surface antigen and core IgG antibodies form. Hepatitis B E antigen is a marker of viral replication and increased infectivity. The natural history of hepatitis B infection is dependent on the age at which an individual is infected. For those over the age of 5 years, higher than 95% of cases are self-limited and the virus is cleared from the body with lasting immunity within 6 months. A small percentage of patients develop chronic hepatitis B and are at risk for cirrhosis and hepatocellular carcinoma. High risk groups included healthcare workers, men who have sex with men, injection drug users and persons with multiple sexual partners. As this case illustrates, physicians need to be aware of the possibility of breakthrough infection in vaccinated patients and be cognizant of risk behaviours."