Age: 46.0
Sex: M
Vaccine: FLUX, FLUX, FLU3, FLUX
Symptoms: Tenosynovitis, Ultrasound scan abnormal, White blood cell count normal
Clinical narrative: This literature report (initial receipt 20-Mar-2012) concerns a 46 year old male patient. This article describes a case of progressive osteolysis and surface chondrolysis of the proximal humerus following routine influenza vaccination that required surgical intervention. On an unknown date, the patient received influenza vaccination (brand unknown). The patient presented with left shoulder pain of 3 weeks duration, which started immediately following an influenza vaccination in the left deltoid area. He reported no recent trauma, and the left shoulder had been asymptomatic preceding the vaccination, including a complete recovery from an open Bankart repair performed 13 years previously. The patient was healthy, with no medical comorbidities, and reported no previous corticosteroid use or alcohol abuse. There was no history of hemoglobinopathy, connective tissue disorder, recent traumatic event or occupational hazard (Caisson disease). The vaccination was given with a 1-inch needle and placed into the left deltoid muscle in a lateral and proximal position, approximately 2 cm distal to the lateral aspect of the acromion. No immediate vaccination complications or infectious changes of the skin occurred. Left shoulder discomfort began a few days following the injection, progressively worsened, and partially subsided with non-steroidal anti-inflammatory drugs (NSAIDS). The pain was localized to the anterior shoulder joint and was exacerbated with overhead activities. Initial examination demonstrated a healthy-appearing man with no excessive muscle mass or subcutaneous fat surrounding the shoulder girdle. No changes of the skin were noted. Forward flexion (150), external rotation (35 degrees), and internal rotation (L2) were limited compared with the unaffected side (160 degrees, 45 degrees, T7, respectively). He had tenderness over the biceps tendon and deltoid laterally. O'Brien's and Speed's tests were positive. Plain radiographs revealed a small lytic area involving the greater tuberosity of the humeral head and surgical changes relating to Bankart repair. Magnetic resonance imaging (MRI) revealed abnormal uptake and cystic changes involving the greater tuberosity of the humeral head. MRI revealed no subchondral hyperemia, fracture or collapse. No bone marrow changes occurred, consistent with early osteonecrosis of the humeral head. Bone scan revealed isolated increased signal intensity involving the lateral aspect of the humeral head. Conservative management over the next 5 months, including NSAIDS and occupational therapy, was unsuccessful. No cortisone injection were administered. The patient's left shoulder pain and disability worsened, and he was unable to return to normal activities of daily living. Follow-up revealed continued tenderness over the biceps tendon and further limitation on internal rotation to L5. Laboratory results, including white blood cell count, C-reactive protein, and erythrocyte sedimentation rate, were normal. Repeat MRI of the left shoulder revealed progression of the cystic changes and abnormal signal uptake involving the greater tuberosity of the humeral head. The patient's clinical dysfunction was worsening, and the greater tuberosity cyst was rapidly enlarging despite conservative measures. Surgical intervention was recommended. The patient underwent diagnostic arthroscopy of the shoulder and open biopsy of the cystic area involving the greater tuberosity. Arthroscopy revealed a hyperemic joint capsule and extensive chondrolysis involving approximately 50% of the articular surface of the humeral head with a central, full thickness defect. Hyperemia of the exposed subchondral bone was noted. The glenoid demonstrated minimal chondral fraying. The biceps tendon was intact but hyperemic and consistent with tenosynovitis. No intra-articular interventions were performed during this initial surgical procedure except thorough arthroscopic irrigation. During open biopsy of the humeral greater tuberosity, the lateral cortex was softened, and when opened, a serosanguinous fluid existed. The area was thoroughly debrided, and bone grafting was initially delayed due to concern for possible infection because the intraoperative frozen section was inconclusive. The cultures obtained intraoperatively were negative for infection and showed no histological evidence of osteonecrosis. Pathological examination of surgical specimens demonstrated inflammatory cells and granulation tissue, consistent with reactive disease or foreign-body response. The progressive humeral lesion and inflammatory component was attributed to a reaction following the influenza vaccination, most likely given intraosseously. In addition, the extensive humeral head chondrolysis and biceps tendonitis were likely an inflammatory reaction to the injection and contributed to the patient's dysfunction and pain. Therefore, the patient underwent resurfacing of the proximal humerus and biceps tenodesis. Full-thickness chondral defects were probably resolved with time following the initial debridement. The area of the lateral humeral head osteolysis was treated with prosthetic humeral head surfacing and biceps tenodesis. Post operative rehabilitation with physical therapy guidance was essential to complete resolution of symptoms. Postoperatively, the patient completely additional physical therapy and was weaned off all narcotics and NSAIDS. At most recent follow-up > 3 years postoperatively, the patient had pain-free ROM (range of motion) of the left shoulder and excellent alignment, and had returned to all activities. The event outcome was recovered. Reporter's comments: We present the first reported case of progressive osteolysis and reactive chondrolysis following influenza immunization. Intraarticular and intraosseous vaccination placement is thought to be the reason for the observed findings. We were uncertain whether chondrolytic changes of the humeral head were present or established at the initial arthroscopy > 10 years prior to influenza immunization. However the patient's shoulder was asymptomatic and fully functional for > 2 years prior to vaccination and became problematic following vaccination. The patient had no underlying genetic disorder, his shoulder dysfunction and radiographic evidence of osteolysis coincided with the influenza immunisation. The influenza immunization caused inflammatory changes in the shoulder joint as confirmed with arthroscopic visualization and histopathologic examination, which likely induced humeral head chondrolysis or converted an asymptomatic chondrolysis process to a symptomatic shoulder condition with limited ROM and function. We report humeral head osteolysis and surface chondrolysis as a potential complication following improper immunization placement.