Sex: M
Vaccine: HEPAB
Symptoms: Cryoglobulinaemia, Cryoglobulins absent, Decreased appetite, HIV infection, HIV test
Clinical narrative: Vaccination failure; Hepatitis B infection; Serum sickness-like reaction; Swelling, stiffness and tenderness of the knees, ankles, bilateral metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints; stiffness and tenderness of the knees, ankles, bilateral metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints; stiffness and tenderness of the knees, ankles, bilateral metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints; painful, pruritic rash on his feet; painful, pruritic rash on his feet; painful, pruritic rash on his feet; Minimal effusion and tenderness was noted in both knees; non-blanching erythematous macular rash; non-blanching erythematous macular rash; abdominal pain; nausea; vomiting; anorexia; This case was reported in a literature article and described the occurrence of vaccination failure in a 36-year-old male patient who received HAB (Hepatitis A and Hepatitis B vaccine) for prophylaxis. Serum Sickness-Like Reaction Associated With Acute Hepatitis B in a Previously Vaccinated Adult Male. DOI: 10.7759/cureus.14742.)  Concurrent medical conditions included hypertension, heroin addiction (active intravenous heroin drug use and participated in sharing needles) and chronic hepatitis c (untreated and acquired two years prior while incarcerated).   On an unknown date, the patient received Hepatitis A and Hepatitis B vaccine. On an unknown date, more than a year after receiving Hepatitis A and Hepatitis B vaccine, the patient experienced vaccination failure (serious criteria hospitalization and GSK medically significant), hepatitis b (serious criteria hospitalization and GSK medically significant), serum sickness-like reaction (serious criteria hospitalization), swollen joints, stiff joint, joint tenderness, itchy rash, rash, pain, knee effusion, red rash, macular rash, abdominal pain, nausea, vomiting and anorexia. The patient was treated with naproxen, sulfamethoxazole + trimethoprim (Trimethoprim-Sulfamethoxazole) and methadone. On an unknown date, the outcome of the vaccination failure was unknown and the outcome of the hepatitis b, serum sickness-like reaction, swollen joints, stiff joint, joint tenderness, itchy rash, rash, pain, knee effusion, red rash, macular rash, abdominal pain, nausea, vomiting and anorexia were recovered/resolved.   The reporter considered the vaccination failure, hepatitis b, serum sickness-like reaction, swollen joints, stiff joint, joint tenderness, itchy rash, rash, pain, knee effusion, red rash, macular rash, abdominal pain, nausea, vomiting and anorexia to be possibly related to Hepatitis A and Hepatitis B vaccine.  Additional details were provided as follow: This case was reported in a literature article and described the vaccination failure in a 36-year-old male patient who was vaccinated with unspecified hepatitis A and hepatitis B Vaccine (manufacturer unknown) for prophylaxis. The patient had medical history of essential hypertension, active intravenous heroin drug use and participated in sharing needles. The patient also had chronic untreated hepatitis C acquired two years prior while incarcerated. The patient was identified as heterosexual and denied sexual activity in the last six months or history of travel in the preceding months. The patient was living with a male friend who had chronic hepatitis B infection. No information on the patient's family history or concomitant medication was provided. On an unspecified date, more than a year prior to the development of his presenting symptoms, the patient had completed vaccination series for hepatitis A and hepatitis B vaccine (administration route and site unspecified; batch number not provided). The age of vaccination was not provided. On an unspecified date, more than a year after the vaccination, the patient presented with two-weeks history of swelling, stiffness and tenderness of the knees, ankles, bilateral metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints. The patient also presented with three days of a painful, pruritic rash on his feet, with cephalic spread to involve lower abdomen and upper limbs. The patient attempted self management with daily naproxen and two days of oral trimethoprim-sulfamethoxazole with no improvement. On examination, the patient was afebrile 36.7 C, blood pressure 142/87 mmHg, respiratory rate of 18 breaths a minute, heart rate 104 beats a minute. The patient was able to ambulate with discomfort but without support. Minimal effusion and tenderness was noted in both knees, with bilateral ankle tenderness and restricted motion; point tenderness over the cervical spine and bilateral symmetric MCP and PIP tenderness was also noted. No joint deformity was present. Tender, non-blanching erythematous macular rash was noted over the bilateral lower extremities, extending to the penis, scrotum, lower abdomen and upper extremities, with sparing of the palms and soles. Initial examination was negative for jaundice, abdominal distension and ascites. Preliminary workup was remarkable for elevated liver enzymes [aspartate transaminase (AST) 375, alanine transaminase (ALT) 502], mildly elevated erythrocyte sedimentation rate (ESR) (40), C-reactive protein (CRP) (13), normal international normalised ratio (INR) (1.09), normal creatinine (Cr) [blood urea nitrogen (BUN) 16, Cr 0.5)]. The patient was initially managed supportively with methadone for pain, with a working diagnosis of undifferentiated vasculitis. Two days into his admission, the patient developed abdominal pain, nausea, vomiting and anorexia. At this point, examination was positive for diffuse abdominal tenderness without hepatosplenomegaly. Differential diagnosis included cryoglobulinemia secondary to chronic hepatitis C, contaminated heroin with an unknown agent causing vasculitis, acute hepatitis B infection, HIV infection and autoimmune vasculitis. Further investigative workup was ordered including complement levels, rheumatoid factor, cryoglobulins, hepatitis A IgM, hepatitis B serologies, 4th generation Ag/Ab HIV, quantitative and qualitative hepatitis C RNA, hepatitis C antibody, urinalysis (UA) and blood cultures. Results showed negative cryoglobulins, antineutrophil cytoplasmic antibody (ANCA), UA, blood culture and hepatitis A IgM; low C4 and normal C3 complements, quantitative hepatitis C virus (HCV) RNA PCR 32 IU/ml. Hepatitis B panel was positive for core antibody IgM, surface antigen, and e antigen. Hepatitis B virus (HBV) RNA PCR viral load was 214 million IU/ml. A diagnosis of serum sickness-like reaction associated with acute hepatitis B infection was consistent with clinical features, risk factors and laboratory parameters. The patient left the hospital against medical advice, having received symptomatic treatment with methadone prior to leaving. At follow-up eight months later, the patient's symptoms had resolved. The patient remained positive for hepatitis B core antibody, hepatitis B e antibody and tested negative for hepatitis B surface antigen and hepatitis B surface antibody. The follow-up hepatitis B panel indicates either a resolved infection of hepatitis B, or a low-level chronic infection with hepatitis B. Follow-up laboratory assessment two years later revealed the same serology results, with the exception of hepatitis B core antibody which was not obtained at the time. The patient's HBV DNA quantitative level was less than 10 IU/ml during this follow-up. This case has been considered as vaccination failure. This case has been considered serious due to hospitalization and vaccination failure.  The patient's symptoms of rash and arthralgias subsided with resolution of acute hepatitis B infection. The authors commented that, "Serum sickness-like reaction (SSLR) has been described in about 10%-20% of patients with acute hepatitis B Infection. The disease clinically manifests as a prodromal illness with symptoms ranging from erythematous macular or maculopapular rash to arthralgia with or without joint swelling. Typically, low levels of complement proteins are expected with serum sickness, however normal levels of C3 and C4 might be observed on admission. Failure to attain seroconversion after complete hepatitis B vaccination is the most likely reason for our patient's positive hepatitis B serology and clinical presentation. Our patient presented with typical symptoms, however, suspicion was initially low for acute hepatitis B infection, given that he had documented hepatitis B vaccination. The patient also had evidence of chronic hepatitis C infection, however, his viral load was low and we considered it to be unlikely that he would develop SSLR from his chronic HCV infection, since he was not immune compromised. Aiding us in this diagnosis was our further probing into the patient's history of intravenous drug use and sharing of needles with a roommate who had chronic hepatitis B infection. The patient's symptoms of rash and arthralgias subsided with resolution of acute hepatitis B infection, further making the case for a hepatitis B-related immune phenomenon. It is possible to acquire hepatitis B infection despite complete vaccination series. Serum sickness-like reaction as the initial presentation of acute hepatitis B infection in a person who has completed vaccination is uncommon but should remain in the clinician's differential.". The authors concluded that, "It is important to keep in mind atypical ways in which hepatitis B may present, including extrahepatic manifestations in a patient who has been fully vaccinated".