Age: 88.0
Sex: F
Vaccine: FLUX, FLUX
Symptoms: Thrombocytopenia, Urine analysis normal
Clinical narrative: Case number PHHY2016US118590 is an initial literature report received on 27 Aug 2016. The author presented the case of a patient who had leukocytoclastic vasculitis (LCV) during the fall season of 2 consecutive years. This report refers to an 88 year old female patient with well controlled diabetes mellitus and hypertension. She also had paraproteinemia. She was vaccinated with influenza vaccine (manufacturer and batch number: not reported) on an unknown date. On an unspecified date, she presented with a 3 day history of a pruritic eruption on the legs. On examination, she had non-blanching erythematous-to-violaceous macules that coalesced into patches, in addition to palpable purpura, on the bilateral lower extremities. She otherwise felt well and denied fever, chills, dysuria, nausea, vomiting, abdominal pain or upper respiratory symptoms. She denied taking new medications. Biopsy findings from a purpuric papule on the thigh were consistent with leukocytoclastic vasculitis. Complete blood count showed mild anemia and thrombocytopenia. Urinalysis result was within normal limits. Without an obvious infection or medication trigger, the patient's history of paraproteinemia was suspected as a possible inciting factor. The hematology department determined that there was a possibility of lymphoma; however, the patient was otherwise asymptomatic and elected to monitor rather than intervene. Five days after the initial presentation, the eruption was markedly improved with predominantly post inflammatory hyperpigmentation remaining. Complete resolution occurred within 3 weeks. The seriousness of the events was not reported, but the event leukocytoclastic vasculitis was upgraded as medically significant based on the NVS-IME list. A cause of the events could not be identified at the time of the initial presentation. One year later the patient was vaccinated with influenza vaccine (manufacturer and batch: not reported) and presented with a recurrence of scattered erythematous non-blanching macules and palpable purpura on the bilateral lower extremities (see related case number: PHHY2016US118696). Chart review revealed that the patient had received the influenza vaccine 11 days before onset of second eruption. Upon further investigation, it was discovered that the patient had received influenza vaccine 11 days before the onset of initial eruption. The final diagnosis was suspected to be LCV secondary to the influenza vaccine, given the identical onset of the episodes 11 days after vaccination and complete resolution between the 2 exposures. There was no disease activity between episodes and the patient showed no sign of systemic involvement. The history of paraproteinemia was without evidence of clinically significant lymphoma on recent imaging. The patient was counseled to avoid the influenza vaccine next year. The author stated that there were no common risk factors for LCV identified in the previous cases aside from the administration of a vaccine and hence further research should be conducted to determine a causative link between LCV and vaccinations. The temporal nature of these cases of vasculitis following vaccination suggested an immunopathogenic link that has yet to be explained. The author also stated that it was interesting to consider the role of paraproteinemia in this case. Although the timing of the patient's episodes of LCV provided strong support for the vaccine's role, the possibility that an underlying paraproteinemia might have made the patient more susceptible to the eruption must be considered. Previous cases attributed to a vaccine had no other identified precipitating factors. The author proposed to perform a thorough search for additional etiologic agents such as paraproteinemia, particularly in a patient with recurrent LCV. No further information was provided.