Age: 54.0
Sex: F
Vaccine: FLUX
Symptoms: Antibody test normal, Biopsy muscle abnormal, Blister, Blood fibrinogen normal, Blood immunoglobulin G normal
Clinical narrative: Initial report received on 25 January 2010 from a literature citation. "A 54 year old healthy female presented with a two week history of a severely pruritic, vesiculobullous eruption on her legs, arms and lower abdomen that developed two days after she had received an influenza vaccine (trade name/manufacturer unspecified) intramuscularly. The rash began as tiny pink papules that then formed vesicles. She continued to get new lesions despite taking Diphenhydramine and Cetirizine as prescribed by her primary care physician. She had not tried topical corticosteroids or any other treatments. She denied changes in her medications, use of herbal supplements or other over-the-counter medications. She denied fever, chills, upper respiratory or gastrointestinal symptoms, or mucous membrane involvement. Her past medical history significant for osteoporosis, hyperlipidemia, and depression. Her medications were alendronate, calcium, vitamin D, rosuvastatin, and sertraline at the time her eruption began. The only recent change in her medication was substitution of generic sertraline for brand name Zoloft, which had occurred two months prior to the eruption. Otherwise, she had been on rosuvastatin for five months and her other medications for over one year. She discontinued rosuvastatin and switched back to brand name Zoloft with no improvement. Physical examination revealed symmetrically distributed discrete, pink papules, vesicles and bullae over her lower extremities, hands, forearms, and lower abdomen with particular concentration on the medial surfaces of her calves. She had no conjunctival injection, involvement of mucous membranes, palms or soles. Microscopic examination of a biopsy from the left calf revealed a subepidermal blistering process with neutrophils. Direct immunoflourescence revealed linear deposits of immunoglobulin A (negative IgG, IgM, C3, and fibrinogen) along the basement membrane zone. These findings in conjunction with histology were most suggestive of LABD. Routine laboratory tests were normal including complete blood count and antiendomysial antibodies. The eruption cleared after two coursed of prednisone followed by a mid-potency topical corticosteroid and did not recur when she restarted generic sertraline and rosuvastatin. The eruption lasted six weeks in total. To our knowledge, this is the first report of LABD associated with the influenza vaccination. Linear IgA Bullous Dermatosis my be idiopathic, but given the temporal associate between the influenza vaccination and onset of the eruption we feel the immunization was the likely trigger. Our patient's medications, namely alendronate, calcium, vitamin D, sertraline and rosuvastatin, have never been reported in association with LABD. On case report cited atorvastatin as a cause of LABD in a patient who began the medication two weeks prior to development of the eruption. However, in our case, the patient's medications were unlikely culprits as she had been on them for many months when the eruption began. Furthermore, the eruption resolved while she continued to take alendronate, calcium and vitamin D and did not recur when she restarted generic sertraline and rosuvastatin. Thus, it seems plausible that the influenza vaccination prompted development of LABD in this patient. Although a rechallenge with influenza vaccination followed by redevelopment of LABD would provide stronger Microscopic examination of a biopsy from the left calf revealed a subepidermal blistering process with neutrophils. Direct evidence for a causal relationship, we did not feel that it would be medically advisable for the patient to take this risk and she has not received further influenza vaccinations. In conclusion, for our patient, it is likely that the influenza vaccination triggered her disease. Our patient fits the clinical picture of drug-induced LABD given the temporal association of the eruption, lack of mucosal involvement, and self-limited course. The drug, in her case, was the influenza vaccination triggering LABD."