Age: 32.0
Sex: M
Vaccine: FLU4, PPV, TDAP
Symptoms: ACTH stimulation test abnormal, Abdominal pain, Adrenocortical insufficiency acute, Blood corticotrophin abnormal, Blood potassium increased
Clinical narrative: This case was reported in a literature article and described the occurrence of adrenal crisis in a 32-year-old male patient who received Influenza vaccine Quadrivalent. Co-suspect products included dTpa vaccine and pneumococcal vaccine. The patient's past medical history included pericarditis (recurrent idiopathic pericarditis) and hypotension (persistent hypotension). Concurrent medical conditions included Addison's disease (autoimmune Addison disease (adrenal insufficiency)). Concomitant products included hydrocortisone, dexamethasone and fludrocortisone. On an unknown date, the patient received Influenza vaccine Quadrivalent at an unknown dose, dTpa vaccine at an unknown dose and pneumococcal vaccine at an unknown dose and frequency. On an unknown date, 6 hrs after receiving Influenza vaccine Quadrivalent and dTpa vaccine, the patient experienced adrenal crisis (serious criteria hospitalization and GSK medically significant), fever (serious criteria hospitalization), myalgia (serious criteria hospitalization), abdominal pain (serious criteria hospitalization), vomiting (serious criteria hospitalization), hyponatremia (serious criteria hospitalization), hyperkalemia (serious criteria hospitalization and GSK medically significant) and hypotension (serious criteria hospitalization). The patient was treated with hydrocortisone and Normal Saline. On an unknown date, the outcome of the adrenal crisis, fever, myalgia, abdominal pain, hyponatremia and hyperkalemia were recovered/resolved and the outcome of the vomiting and hypotension were unknown. The reporter considered the adrenal crisis, fever, myalgia, abdominal pain, vomiting, hyponatremia, hyperkalemia and hypotension to be possibly related to Influenza vaccine Quadrivalent and dTpa vaccine. Additional information was provided. This case was reported in a literature article and described the occurrence of adrenal crisis in a 32-year-old male patient who received Unspecified influenza vaccine, unspecified Tdap vaccine (manufacturer unknown). The patient had recurrent idiopathic pericarditis was admitted with persistent hypotension. Workup revealed elevated Adrenocorticotropic hormone (ACTH), low Dehydroepiandrosterone (DHEAS), positive ACTH stimulation test and positive 21-hydroxylase antibody consistent with autoimmune Addison disease. Maintenance hydrocortisone, 20 mg in the morning and 5 mg at night, as well as fludrocortisone 0.05 mg daily, were started. He was counselled on the use of emergency dexamethasone injection pens. One month after discharge, he had normal sodium and potassium levels and a renin level of 3.0ng/mL/h. No information on patient's family history was provided. On an unspecified date, the patient received unspecified influenza vaccine, unspecified Tdap vaccine and an unspecified pneumococcal vaccine (administration route and site unspecified; batch number not provided for all the vaccines). On an unspecified date, 6 hours after vaccination the patient developed fever, myalgias, abdominal pain and vomiting that prevented intake of oral steroids. In the emergency department, vital signs revealed fever of 39.5 degree C and hypotension of 88/54, with hyponatraemia and hyperkalaemia. Upon admission to the intensive care unit for adrenal crisis, he received 4 L of normal saline and stress-dose IV hydrocortisone for 24 h. The patient's gastrointestinal symptoms quickly resolved after steroid administration and his sodium and potassium normalised. He was discharged on his home steroid regimen and was instructed to triple his home steroid regimen with any future vaccinations. This case has been considered serious due to hospitalization. The author commented, "The vaccines this patient received all can cause fever or gastrointestinal symptoms in adults, at incidence percentages of 6 and 15.9% for Tdap, 2 and 2% for pneumococcal, and 1.6 and 6.5% for influenza, respectively. The patient in this case developed a febrile illness with vomiting after receiving all three vaccinations at once, resulting in adrenal crisis." The author stated, "This case brings into question the optimal method by which we should administer indicated vaccines to patients with adrenal insufficiency. It is unclear if immunisations represent a significant enough physiologic stressor to precipitate adrenal crisis. It is more likely that the magnitude of these stressors varies from patient to patient, and if an immunisation causes the known adrenal crisis precipitants of fever or gastrointestinal symptoms, then these patients should be treated with stress-dose steroids."