Sex: F
Vaccine: FLUX
Symptoms: Drug ineffective, Eosinophilia, Epidermal necrosis, Fixed eruption, Full blood count normal
Clinical narrative: Initial information received from literature on 20-Oct-2018. Introduction: Fixed drug eruption (FDE) is a type IV hypersensitivity reaction characterized by recurrence of lesions at identical sites with each exposure to the offending medication. After morbilliform exanthems, FDE is the most common cutaneous drug reaction.1 Generalized bullous fixed drug eruption (GBFDE) is a variant of FDE that can present rarely with significant, life-threatening body surface involvement akin to Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN).2 There are few reported cases of GBFDE occurring after the influenza vaccine, and all occurred after decades of receiving the vaccine.3,4 Here we report a rare case of GBFDE occurring as a result of administration of the influenza vaccine. This case involves a 67 years old female patient who experienced Fixed eruption, Skin hyperpigmentation, Rash erythematous, Dermatitis bullous, blister, Dermatitis, Epidermal necrosis, Bloch-Sulzberger syndrome and Eosinophilia, while she received vaccine INFLUENZA VACCINE (QUADRIVALENT) and new lesions continued to appear, now covering 15% of her total body surface area while treated with CLOBETASOL and PREDNISONE. The patient's past medical history included Type 2 diabetes mellitus, Hypertension, Chronic obstructive pulmonary disease, Coronary artery disease and Skin hyperpigmentation with postinflammatory hyperpigmentation as a result of a similar bullous eruption after the influenza vaccine 1 year prior. Patient had a background of numerous hyperpigmented patches coalescing on the back, flanks, and buttocks consistent with postinflammatory hyperpigmentation as a result of a similar bullous eruption after the influenza vaccine 1 year prior. Concomitant medications not reported. On an unknown date, the patient started taking CLOBETASOL dosage unknown (with an unknown batch number) and PREDNISONE dosage unknown oral (with an unknown batch number). On an unknown date, the patient received a dose of suspect INFLUENZA VACCINE (QUADRIVALENT) produced by unknown manufacturer lot number not reported. On an unknown date, the patient developed a serious generalized bullous fixed drug eruption (fixed eruption) 3 days following INFLUENZA VACCINE (QUADRIVALENT), and three days after administration of the quadrivalent influenza vaccine, she presented with multiple 2.5- to 5-cm hyperpigmented patches and plaques with a peripheral rim of erythema some with overlying flaccid bullae, located on her bilateral hips and lower back, Although a feworal erosions involving the hard palate and vermilion lips were present, there was no evidence of ocular or genital mucosal involvement. There was complete sparing of the distal extremities including the palms and soles. She remained afebrile with a normal complete blood count and comprehensive metabolic panel. On an unknown date, Biopsy found vacuolar interface dermatitis with subepidermal vesicle formation, epidermal necrosis, marked pigment incontinence, and mild lymphoeosinophilic infiltrate These findings were consistent with the biopsy results from 1 year prior. The episode at that time was of a similar clinical presentation and resolved after 7 days of topical clobetasol 0.05% ointment. During the second bullous eruption, the patient required use of both topical clobetasol ointment and an oral prednisone taper. Within 2 days of hospitalization, new lesions continued to appear, now covering 15% of her total body surface area. The patient was transferred to the burn intensive care unit for aggressive wound care, patient was discharged after 14 days in the burn intensive care unit, with complete resolution at 30 days. It was also a case of lack of drug effect. Histopathologic features included: Vacuolar interface dermatitis with lymphoeosinophilic infiltrate and pigment incontinence, 6 dyskeratotic keratinocytes, Lymphocytic vacuolar interface dermatitis, dyskeratosis throughout all layers of epidermis, Confluent epidermal necrosis, minimal inflammatory infiltrate, Full-thickness epidermal necrosis, minimal inflammatory infiltrate. Other lab tests not reported. Final diagnosis was Fixed eruption, Skin hyperpigmentation, Rash erythematous, Dermatitis bullous, blister, Dermatitis, Epidermal necrosis, Bloch-Sulzberger syndrome and Eosinophilia, Other corrective treatment was not received. The patient outcome is reported as Recovered / Resolved on an unknown date for all the events. List of document held; Sender's Comments: Patient experienced Fixed eruption, Skin hyperpigmentation, Rash erythematous, Dermatitis bullous, blister, Dermatitis, Epidermal necrosis, Bloch-Sulzberger syndrome and Eosinophilia after received INFLUENZA VACCINE (QUADRIVALENT), CLOBETASOL and PREDNISONE..Time to onset is unknown. However, further information including patient's medical history, concomitant medications, condition at the time of vaccination, laboratory investigations excluding other etiology would be needed to fully assess this case. Based on available information and involvement of other drug, the role of individual component cannot be assessed.