Age: 71.0
Sex: M
Vaccine: FLUX
Symptoms: Normocytic anaemia, Polymyalgia rheumatica, Pyrexia, Red blood cell sedimentation rate increased, Rheumatoid factor negative
Clinical narrative: This is a literature case, initially received on 15-Oct-2018 and concerns a 71-year-old, adult, male patient. The patient was vaccinated with the standard-dose influenza vaccine yearly for the past few years with no problems. On an unspecified date, the patient was administered with INN Flu Vaccine Seasonal (reported as quadrivalent high-dose influenza vaccine recommended for elderly) (dose, route of administration, anatomical location, batch number, expiry date, trade name, manufacturer: not reported). On an unspecified date, the patient complained of subjective fevers and myalgia that developed within hours after vaccine administration. The patient eventually developed hip and shoulder stiffness with pain that progressively worsened through the following days. The patient denied any infections or sick contacts and reported no new significant changes in his daily activity prior to symptom onset. The patient denied arthralgia, jaw claudication, scalp tenderness, chest pain, abdominal pain, or rash. The patient was treated with acetaminophen and ibuprofen with minimal relief. On an unspecified date, the patient presented with progressive and severe bilateral shoulder and hip stiffness and pain for 2 months. The patient's primary care physician evaluated the worsening symptoms and performed blood work that revealed elevated erythrocyte sedimentation rate (ESR) of 43 mm/h, and the patient was instructed to go to the emergency department for further evaluation. On an unspecified date, the patient was evaluated in the emergency department 2 days later, at which time he was afebrile with ongoing stiffness and pain limiting movement of his shoulder and hip girdle. The patient's physical examination was negative for temporal artery tenderness bilaterally, oral ulcers, muscle weakness, joint synovitis, lymphadenopathy, rash, muscle weakness (limited by his ongoing pain), or tenderness. On 10-Dec-2014, laboratory analysis was pertinent for a normocytic anemia with hemoglobin of 11.7 g/dL; ESR, 75 mm/h; and CRP, 3.0 mg/dL. Rheumatoid factor, antinuclear antibodies, SSA, SSB, human immunodeficiency virus, hepatitis C, and Borrelia burgdorferi antibody tests were negative. Creatinine kinase, aldolase, and thyroid-stimulating hormone were all within normal limits. Subsequently, on an unspecified date, the patient was diagnosed with polymyalgia rheumatica (PMR) based on the 2012 Rheumatology Provisional Criteria with morning stiffness greater than 45 minutes, absence of rheumatoid factor, hip pain, and absence of other joint involvement. Given the severity of his symptoms, the patient was treated with a moderate dose of prednisone (40 mg/d) to which the patient had a dramatic response and was eventually discharged home. On 07-Jan-2015, the patient was seen at follow-up and continued to do well as the prednisone was tapered down. The erythrocyte sedimentation rate value decreased from initial value of 75 mm/h to 31 mm/h and returned to normal as the prednisone was weaned off. The patient was off the steroids for about 6 months. On 16-Sep-2016, the last erythrocyte sedimentation rate value was 6 mm/h. The patient continued to be in remission without signs of giant cell arteritis (GCA) or worsening symptoms thus far. At the time of this report, the outcome of the events was reported to be recovering/resolving. The reporter assessed the events as related to the suspect vaccine. The reporter concluded that the high-dose of the influenza vaccine contained higher amounts of antigen compared with standard flu vaccination, intended to create a stronger immune response. The reporter emphasized the possibility that the higher dose of antigen in the quadrivalent vaccine could have contributed to the development of PMR in the patient, who otherwise did well with the traditional trivalent vaccine which was taken historically.