Age: 89.0
Sex: F
Vaccine: FLUX, FLUX, FLUX
Symptoms: Nuclear magnetic resonance imaging normal, Palpable purpura, Pancytopenia, Papule, Post inflammatory pigmentation change
Clinical narrative: Case number PHHY2016US118696 is an initial literature report received on 27 Aug 2016. The author presented the case of a patient who had leukocytoclastic vasculitis (LCV) during the fall season of 2 consecutive years. This report refers to an 89 year old female patient with well controlled diabetes mellitus and hypertension. She also had paraproteinemia. Her vaccination history included administration of influenza vaccine (manufacturer and batch number: not reported) one year before following which she experienced LCV (see related case number: PHHY2016US118590). She was vaccinated with influenza vaccine (manufacturer and batch number: not reported) on an unknown date.  The patient presented with a recurrence of scattered erythematous non-blanching macules and palpable purpura on the bilateral lower extremities. Similar to the previous episode, review of systems was otherwise negative. She denied taking new medications or having recent infection. Complete blood count showed mild pancytopenia. Urinalysis result was within normal limits. During the interim, the patient had undergone radiologic imaging and had no evidence of a clinically significant lymphoma. Chart review revealed that the patient had received influenza vaccine 11 days before the onset of the current eruption. Upon further investigation it was discovered that the patient also received the influenza vaccine 11 days before the onset of initial eruption 1 year before. The final diagnosis was suspected to be LCV secondary to the influenza vaccine, given the identical onset of the episodes 11 days after vaccination and complete resolution between the 2 exposures. The patient had complete resolution of events within three weeks. The seriousness of the events was not reported, but the event leukocytoclastic vasculitis was upgraded as medically significant based on the NVS-IME list. There was no disease activity between episodes and the patient showed no sign of systemic involvement. The history of paraproteinemia was without evidence of clinically significant lymphoma on recent imaging. The patient was counseled to avoid the influenza vaccine next year. The author stated that there were no common risk factors for LCV identified in the previous cases aside from the administration of a vaccine and hence further research should be conducted to determine a causative link between LCV and vaccinations. The temporal nature of these cases of vasculitis following vaccination suggested an immunopathogenic link that has yet to be explained. The author also stated that it was interesting to consider the role of paraproteinemia in this case. Although the timing of the patient's episodes of LCV provided strong support for the vaccine's role, the possibility that an underlying paraproteinemia might have made the patient more susceptible to the eruption must be considered. Previous cases attributed to a vaccine had no other identified precipitating factors. The author proposed to perform a thorough search for additional etiologic agents such as paraproteinemia, particularly in a patient with recurrent LCV. No further information was provided.