Age: 29.0
Sex: F
Vaccine: FLU(H1N1)
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, Asthenia, Biopsy muscle normal, Blood creatine phosphokinase increased
Clinical narrative: Case number PHEH2012US010788 is an initial combined literature report received on 23 May 2012 with a follow up information received on 29 May 2012. The author presented a case of a young athlete who experienced exertional rhabdomyolysis following vaccination with S-OIV FLUVIRIN and FLUMIST. This report refers to a 29-years-old female patient. Her medical history included occasional use of alcohol and her family history included death of her elder sister due to H1N1 complication. Her concomitant medications were oral contraceptives. Her vaccination history included administration of FLUMIST (other manufacturer, batch number: 5005691P) on 01 Oct 2009. Following FLUMIST vaccination she was admitted in hospital due to exertional rhabdomyolysis (without renal complications) with the symptoms of diffuse muscle pain associated with dark urine and severe upper arm and leg pain exacerbated by movement following a workout consisting of squats, push-ups, sit-ups and shoulder press. Lab tests results were as follow: Creatinine kinase (CK): 66,000; Blood urea nitrogen (BUN): 8; creatinine: 0.8; Aspartate aminotransferase (AST): 441; Alanine aminotransferase (ALT): 220 and Urinalysis: 1.006, small blood and no RBCs. On an unspecified date she was discharged home with aggressive oral rehydration and recommended physical rest. On 23 Nov 2009 she was vaccinated with S-OIV FLUVIRIN (batch number: 102126P1) through unspecified route and site. She had also resumed the low impact exercise again. It was reported that she developed the symptoms again. Due to the recurrence of symptoms, an exercise intolerance mutation panel was done. Physical examination was significant for diffusely tender muscles and pain on passive range of motion (ROM). She also had mild residual upper body weakness. The diagnosis was exertional rhabdomyolysis. She performed several laboratory tests and the results in the second episode were as follows: CK: 1300; BUN: 8; creatinine: 0.8; AST: 99; ALT: 40 and Urinalysis: 1.001, small blood and no RBCs. It was reported that the exercise intolerance mutation panel showed no mutations for myophosphorylase deficiency, carnitine palmitoyltransferase 2 deficiency or myoadenylate deaminase deficiency. Her muscle biopsy was negative. As per the reporter, the patient was used to eccentric exercise and it seemed rare that she would develop unprecipitated symptoms of rhabdomyolysis without a predisposing factor. The outcome of the event was reported as condition improving. The reporter assessed the event of exertional rhabdomyolysis as related to S-OIV FLUVIRIN and FLUMIST. The author concluded the article stating that given the timeline of live virus influenza vaccines 3 weeks prior to each episode of symptoms, as well as a negative genetic work up, it was hypothesized that the live influenza virus vaccine in combination with eccentric exercise caused rhabdomyolysis; however, further investigation revealed that the patient had received an inactivated parenterally administered H1N1 vaccination approximately three weeks after receiving FLUMIST, not a second live virus vaccine.