Age: 33.0
Sex: M
Vaccine: FLUX, FLUC4
Symptoms: Injection site pain
Clinical narrative: This spontaneous case, reported by other healthcare professional to VAERS and initially retrieved on 16-Aug-2018 by Seqirus from VAERS (VAERS ID: 719556), concerns a 33-year-old, adult male patient. The patient's vaccination history included a flu shot and his historical condition included depression. The patient had no current illnesses or any known allergies. The patient's medications at the time of vaccination included, fish oil tablets. On 02-Oct-2017, the patient was administered FLUCELVAX QIVc [dose: 0.5 ml, route of administration: intramuscular, anatomical location: left arm, batch number: 195217, expiry date: not reported]. On the same day (reported as Monday) after vaccination, the patient experienced left deltoid soreness which persisted for the first 2 days. It was reported that this was not unusual for him as he previously has had similar symptoms after flu shot in the past. On 05-Oct-2017 (reported as Thursday) the events seemed to improve but by 07-Oct-2017 (reported as Saturday), the patient noticed pain while moving his left arm and shoulder a certain way (brushing his hair or lifting his left arm to shoulder height). The patient felt pain in left deltoid area, which was mild in severity. Patient denied bruising, swelling, redness, rashes or warmth at the vaccination site. Patient denied left extremity weakness, numbness or tingling or loss of sensation and no recent injury or fall. The patient denied any tenderness at the left deltoid and only felt it when he raised his arm and denied decrease in mobility or crepitus. The patient did not try to self-treat. The patient used to work out daily until recently with his last workout (chest press, rope pull, dead lifts) being on an unspecified date, reported as 'last Friday'. On an unspecified date, the patient was evaluated in clinic. The patient had active mild pain with motion only of left arm in the deltoid region with otherwise full ROM. The patient's left deltoid muscle was non-tender with no palpable hematoma or visible ecchymosis, or edema, warmth, rashes or shoulder joint tenderness. The patient's skin was intact and strength 5/5 in upper extremities bilaterally. Hand grips was equal and strong bilaterally. The patient was neurovascularly intact. The patient was prescribed 1 tablet of ALEVE, per oral (PO), twice a day (BID) along with food for a week and was advised to apply ice and to continue activity as much as can be tolerated but to avoid left arm or left shoulder straining and activities that could cause pain and overuse. The patient was also told to maintain range of motion (ROM) and was scheduled for a follow up visit in the following week. Patient was not sure if the events were related to the flu vaccine, but wanted to report them and be evaluated. The patient did not undergo any laboratory investigations. It was reported that the patient had visited office. At the time of this report, the patient had not recovered from the events. The reporter assessed this case as non-serious. Update received on 27-Sep-2018: Significant case correction (16-Aug-2018): The event (musculoskeletal pain) was deleted. The repeated sentence 'the patient denied decrease in mobility or crepitus' was removed from the narrative. The case comment amended accordingly.