Age: 70.0
Sex: M
Vaccine: FLUX, FLUX
Symptoms: Red blood cell sedimentation rate increased, Rheumatoid factor negative, Slit-lamp tests abnormal, Treponema test negative, Tuberculin test
Clinical narrative: This medically confirmed literature report (initial receipt 28-Apr-2015) concerns a 70 year-old male patient who had a significant ocular history of bilateral pseudophakia and non-proliferative diabetic retinopathy with macular edema. He had a medical history of well-controlled diabetes mellitus, hypertension and coronary artery disease, which was his status after a four-vessel coronary artery bypass graft operation. On an unspecified date, the patient received Influenza virus vaccine (manufacturer and batch number not provided) for the first time. On an unspecified date, the day after vaccination, the patient began to develop symptoms and presented to the emergency department with a chief complaint of sudden onset of decreased vision in both eyes, which worsened throughout the day. Upon wakening during the night, he noted further worsening in his vision and a dull ache behind the eyes. He denied floaters and photopsias. On ophthalmologic examination, the patient's best-corrected visual acuity was "hand motions" in both eyes. Six months prior, his visual acuity was documented as 20/50 in the right eye and 20/60 in the left eye. Intraocular pressures were elevated at 28 mmHg in the right eye and 38 mmHg in the left eye. Pupils were minimally reactive to light in both eyes, with no afferent pupillary defect in both eyes. Slit-lamp examination showed severe conjunctival injection, diffuse corneal keratic precipitates, nearly 306 degrees of posterior synechiae, and 4+ anterior chamber cells and flare within 1-mm hypopyon in both eyes. B-scan ultrasonography showed vitreous debris, without retinal detachment, vitreous haemorrhage, or masses in both eyes. Visual acuity was 20/300. Laboratory work-up for uveitis was positive for C-reactive protein (2.1 mg/dL), erythrocyte sedimentation rate (32 mm/hour), and mildly positive antinuclear antibodies (1:80) in a speckled pattern, considered nonspecific. Chest x-ray, angiotensin-converting enzyme, rapid plasma reagin, microhemagglutination-Treponema pallidum test, rheumatoid factor, and extractable nuclear antibody study were within normal limits. Lyme titers, HLA-B27, purified protein derivative skin testing, and blood cultures were negative. Treatment included topical steroids (prednisolone acetate 1%) every hour while awake and scopolamine 0.25% twice daily on both eyes. At the 1-day follow-up visit, the patient stated that his vision had improved an ocular discomfort had subsided. On examination, visual acuity was "counting fingers" in both eyes, improved from "hand motions" the day before. The number of corneal keratic precipitates had decreased, the anterior chamber inflammation had diminished in both eyes, and a fibrin clot was developing in the anterior chamber in both eyes. By the following day, the fibrin clot had decreased in size in the right eye and had resolved completely in the left eye. After a short 5-day course of oral steroids and a posterior sub-Tenon's injection of triamcinolone acetate in the right eye, the patient's visual acuity returned to baseline (20/50 in the right eye and 20/60 in the left eye) 3 months after initial presentation. The outcome was recovering. Reporter's comments: The reporter stated that the inflammation was an ocular reaction to the influenza vaccine administered 1 day before the onset of symptoms, and that this case demonstrates that, on rare occasions, a fulminant immune response may manifest as a bilateral panuveitis.