Age: 17.0
Sex: F
Vaccine: HPV4
Symptoms: Inflammation, Keratitis, Nuclear magnetic resonance imaging brain normal, Serology negative, Slit-lamp tests abnormal
Clinical narrative: Information has been received from a literature article concerning a 17 healthy year old female patient developed conjunctival hyperemia of her right eye and was treated with topical VIGAMOX by her primary care physician. Her optometrist diagnosed contact lens associated keratitis and prescribed loteprednol etabonate, ZYLET. On subsequent examination bilateral anterior uveitis grade as 2+ cell and 1 + flare was noted. Tropicamide 1% TID and PRED FORTE Q1 hour along with dexamethasone, TOBRADEX at bedtime were then prescribed. Reduction of inflammation was noted in one week, however the inflammation recurred as topical corticosteroid therapy was tapered. She was referred for systemic evaluation after six weeks because the inflammation remained active. Physical examination and serologic evaluations were performed by her primary care physician and a rheumatologist; however no underlying cause for her uveitis was discovered. Her maternal grandparents had rheumatoid arthritis. Four months after onset of her symptoms she was referred for uveitis consultation due to persistent inflammation despite PRED FORTE OU BID. History obtained at the time disclosed her initial GARDASIL was administered 2 weeks prior to onset of uveitis and her second vaccination was temporally associated with a flare of uveitis when her topical corticosteroid dose was reduced to twice daily. The patient and her family elected to defer the third vaccination in the series. Best corrected visual acuity at the time was 20/20 in the right eye and 20/25 in the left. The conjunctiva was not injected. The cornea was normal in appearance without evidence of scarring or keratic precipitates. The anterior chamber reaction was graded as 3+ cell in both eyes. Trace vitreous cells were present in both eyes on slit lamp bio microscopy, and fluorescein angiography demonstrated late hyperfluorescence of the optic discs. Additional serologic work-up did not disclose any significant abnormalities. Magnetic resonance imaging of brain and orbits with gadolinium contrast was unremarkable. Lumbar puncture was performed with a normal opening pressure. Cerebrospinal fluid analysis was unremarkable. She was treated with CELEBREX 200mg twice daily and topical steroid therapy was eliminated. A trace amount of cells were observed intermittently in the anterior chamber over the course of the next three years without symptoms or sequelae of uveitis Glaucoma consultation was obtained and co-morbid pigment dispersion syndrome was excluded. CELEBREX was discontinued after 32 months of therapy and uveitis symptoms have not recurred after an additional 20 months. Best corrected visual acuity remained 20/20 in both eyes more than 4 years after onset of her symptoms. A total of 24 cases of uveitis occurred following administration of GARDASIL; the gender in all cases was female. The median age was 17. The median time from vaccination to onset of ADRs was 30 days; time to onset was unknown in 1 case; the time to onset in this case was of 14 days from vaccination. There was one reported rechallenge of the GARDASIL. In 13 of the 24 cases other ocular side effects were noted including 3 case reports of papillitis, 2 case reports of retinitis and 1 case report of papilledema. According to World Health Organization Causality Assessment Guide of Suspected Adverse Reactions, the relationship between human papilloma virus vaccination and uveitis was "possible" Causality assessments are based on the time relationship of drug administration, uveitis development and rechallenge data. This is one of several reports form the same literature source. Additional information has been requested.