Sex: F
Vaccine: HEP, HEPA
Symptoms: Acute hepatitis B, Alanine aminotransferase increased, Anti-cyclic citrullinated peptide antibody negative, Arthralgia, Aspartate aminotransferase increased
Clinical narrative: This case was reported in a literature article and described the occurrence of hepatitis B in  52-year-old female patient who received Hepatitis A vaccine. Co-suspect products included Hepatitis B vaccine. The patient's past medical history included heroin addiction (now in remission on SUBOXONE), alcohol addiction, chronic hepatitis C and hepatitis A. Concurrent medical conditions included pain in knee. Concomitant products included Hepatitis B vaccine. On an unknown date, the patient received the 1st dose of Hepatitis A vaccine and the 2nd dose of Hepatitis B vaccine. On an unknown date, an unknown time after receiving Hepatitis A vaccine and Hepatitis B vaccine, the patient experienced hepatitis B (serious criteria hospitalization and GSK medically significant), nausea, vomiting, fatigue, pain in joint involving hand, shoulder pain, condition aggravated, joint swelling of hand and synovitis. The patient was treated with intravenous fluid (nos), ketorolac and ibuprofen. On an unknown date, the outcome of the hepatitis B, nausea and vomiting were recovering/resolving and the outcome of the fatigue, pain in joint involving hand, shoulder pain, condition aggravated, joint swelling of hand and synovitis were not recovered/not resolved. It was unknown if the reporter considered the hepatitis B, nausea, vomiting, fatigue, pain in joint involving hand, shoulder pain, condition aggravated, joint swelling of hand and synovitis to be related to Hepatitis A vaccine. The reporter considered the hepatitis B to be related to Hepatitis B vaccine. It was unknown if the reporter considered the nausea, vomiting, fatigue, pain in joint involving hand, shoulder pain, condition aggravated, joint swelling of hand and synovitis to be related to Hepatitis B vaccine. Additional information was provided: This case was reported in a literature article and described the occurrence of acute hepatitis B infection in a 52-year-old female who was vaccinated with unspecified hepatitis B and unspecified hepatitis A vaccine (manufacturer unknown for both). The patient had a past medical history of chronic knee and ankle pain. She was a former intravenous heroin user and was now in remission on SUBOXONE. She also had an alcohol use disorder and was in remission. The patient had a history of remote hepatitis A infection and chronic untreated hepatitis C infection. No information on patient's family history was provided. No information on patient's concomitant medications was provided. On an unspecified date, the patient had received 2 doses of the hepatitis B vaccine (administration route and site unspecified; dosages unknown; batch number not provided) and 1 dose of the hepatitis A vaccine. The patient never completed either vaccination series. On an unspecified date, an unknown period after vaccination with unspecified hepatitis B and hepatitis A vaccine, the patient presented to the primary care clinic with a week-long history of fatigue, new diffused hand joint pain, worst at the proximal interphalangeal (PIP) joints, bilateral shoulder pain, and worsening of right knee pain. In the clinic, patient's vital signs were unremarkable but due to distress on exam, the patient was referred to the emergency department (ED). The patient's Lyme IgG was negative, erythrocyte sedimentation rate and basic metabolic panel were normal, while the C-reactive protein was elevated at 63.5 mg/L. In the ED, the patient received intravenous fluids and intramuscular ketorolac, and was sent home with ibuprofen. Six days later, the patient returned to the clinic with persistence of diffused joint pain and interval development of hand joint swelling. The patient's vitals were again unremarkable though her exam revealed synovitis of the PIP joints bilaterally. Further testing revealed a positive rheumatoid factor, a positive hepatitis B core antibody, and elevated liver transaminases with aspartate transaminase (AST) at 291 U/L and alanine transaminase (ALT) at 607 U/L and serum cryoglobulins were also detected. The patient's symptoms continued to worsen and five days later the patient was sent to the ED because of nausea, vomiting, and worsening polyarthralgias. In the ED, the patient had an abdominal CT scan that revealed perihepatic lymph nodes and an abdominal ultrasound that showed mild splenomegaly and was discharged home. At the follow-up clinic visit, the patient was found to have persistent joint pain. Anti-cyclic citrullinated peptide antibody was negative. However, the patient's Hepatitis B viral (HBV) load was found to be greater than 8 million with a positive Hepatitis B core IgM antibody and the patient was then admitted to the hospital for acute hepatitis B management. She received ketorolac and opiates for pain control. The patient's AST and ALT peaked at 690 U/L and 1022 U/L respectively. The patient's alkaline phosphatase peaked at 525 U/L, from a baseline of about 110. The patient's hepatitis C viral load was noted to be 3355 IU/mL. At discharge, her AST and ALT had normalized and the HBV viral load was noted to be 132 lU/mL. The case was considered serious due to hospitalisation. The patient improved from the symptoms of nausea and vomiting, but arthralgia and fatigue persisted, likely due to the presence of untreated cryoglobulin positive chronic Hepatitis C. The author stated "the patient exposure to Hepatitis B was thought to be an unprotected sexual encounter with a Hepatitis B positive partner. The patient did not complete vaccination series and therefore an antibody titer was not obtained prior to the onset of her symptoms." The authors stated that "the anti-HBV vaccine can and should be used to mitigate the possibility of developing severe acute hepatitis in those individuals with chronic hepatitis C. However, in those individuals who are at risk for a poor immunologic response to the standard.