Age: 55.0
Sex: M
Vaccine: HEPA, YF
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, Blood bilirubin increased, CD4 lymphocytes decreased, CD8 lymphocytes decreased
Clinical narrative: Initial report was retrieved from the scientific literature on 01 July 2013.The following was taken verbatim from the report: "We present a case study in which we measured the antiviral immune response of a kidney transplant recipient who received intravenous immunoglobulin (IVIG) as a precautionary step to reduce the risk of vaccine-associated viscerotropic disease after YFV vaccination. In 2007, a 55-year-old male kidney transplant (KTX) patient received live attenuated YFV-17D vaccine (Sanofi-Pasteur) in addition to concurrent immunization with an inactivated hepatitis A vaccine in preparation for a trip. The subject was 19 years post-deceased donor KTX and receiving maintenance immune suppression with cyclosporine (100 mg twice daily) and mycophenolic acid (360 mg twice daily). Shortly after immunization, the patient reviewed the vaccine contraindications and, realizing the risks associated with his vaccination, he contacted his nephrologist, who then contacted Transplant Infectious Disease for further consultation. Because viremia could not be monitored in real-time, liver enzymes were followed as a marker for yellow fever associated viscerotropic disease (YEL-AVD), a potentially life-threatening condition that results in virus dissemination and multiorgan failure. Prior to vaccination, the subject had average aspartate aminotransferase (AST) values of 28 units/mL and alanine aminotransferase (ALT) levels of 27 units/mL. At 11 days post-vaccination, the patient did not report having a fever, but AST and ALT levels had increased to 60 and 53 units/mL, respectively. IVIG was administered on days 20, 21, and 22 postimmunization, with a daily dose of 500 mg/kg. AST and ALT levels had returned to normal by day 18 postvaccination, but total bilirubin was elevated (2.4 units/mL) at day 25 post-vaccination. On day 26 (i.e., 4 days after final IVIG administration), the patient reported what may have been an urticarial or eczematous response on his face that resolved within 5 days. Total bilirubin, AST, and ALT levels were within normal range when examined at day 47 postvaccination. Follow-up with the patient at approximately 8 months post-vaccination indicated no long-term adverse events. Retrospective testing was performed on patient blood samples and on the IVIG lot administered to the KTX patient. The IVIG lot yielded a YFV-specific 50% plaque reduction neutralizing test (PRNT50) value of 320, demonstrating the presence of YFV-specific neutralizing antibodies similar to 10 other lots of IVIG samples across four vendors (geometric mean PRNT50, 226; range, 80Y320). Blood samples were drawn from the patient at 20, 47, and 246 days after vaccination and analyzed for YFV-specific neutralizing antibody as well as CD4+ and CD8+ T cell responses. For comparison, the immune response of eight healthy adults at 30 days after YFV-17D vaccination were examined. The patient seroconverted by 20 days postvaccination with antibody titers within the lower range of the controls. In contrast to neutralizing antibody levels, the patient's virus specific CD4+ and CD8+ T-cell responses remained below detection (i.e., equivalent to naive controls) at all time points examined. Although it is unknown if IVIG prevented viral dissemination or viscerotropic disease, it did not appear to inhibit successful YFV vaccination as judged by seroconversion. These results suggest that IVIG could be administered as a precaution against potential YFV-AVD or other YFV vaccine associated adverse events." The patient's outcome was recovered. Documents held by sender: none.