Age: 46.0
Sex: M
Vaccine: HEP
Symptoms: Peripheral ischaemia, Raynaud's phenomenon, Red blood cell sedimentation rate increased, Red blood cells urine, Rheumatoid factor negative
Clinical narrative: Case reference number B0986716A was reported in a literature article and refers to a 46-year-old male subject who started developing symptoms of Raynaud's syndrome one week after receiving the first dose of an unspecified recombinant hepatitis B vaccine on an unspecified date (manufacturer, batch number, dose and injection site unknown). The subject is reported to have been healthy prior to the event. No other information on the subject's medical, family history or concurrent medication is available. A 46-year-old male subject presented to his primary care physician complaining of bilateral throbbing finger pain that was worse in the cold, at rest and at night, purplish discoloration, finger numbness and lightheadedness one week after receiving the first dose of an unspecified recombinant hepatitis B vaccine on an unspecified date (manufacturer, batch number, dose and injection site unknown). No information has been provided regarding any clinical examination or investigations performed on the subject during this visit. The subject presented to an emergency department one week later with concerns of digital ischemia. Once again, no information has been provided regarding any clinical examination or investigations performed on him; but the authors report that he was advised to take ibuprofen that was discontinued after three days due to lack of relief. The subject was admitted one week later (three weeks after vaccination) to hospital with the same symptoms and a 3-day history of black tarry stools. On clinical examination he was noted to have bilateral tender and edematous fingertips, splinter hemorrhages under all the fingernails and some duskiness to the fingertips of the thumb and index finger on the right hand. Laboratory findings were relevant for mild anemia, ESR 39, CRP 2.0, Normal C3 156, elevated C4 46 and CH 50 higher than 63. ANA was 1:100 nucleolar patterns. Rh factor, scleroderma and hepatitis and ANCA panel were negative. Anti histone Ab, Anti-IgG and Anti C3d were negative. Urinalysis revealed a trace of albuminuria and few RBCs. Occult blood was positive. Bilateral upper extremity CT angiogram revealed narrowing of the radial arteries and distal phalangeal arteries consistent with small vessel vasculitis. Chest X-ray and echography were normal. Abdomen scan revealed signs of small intestinal vasculitis. Diagnosis was Raynaud's syndrome with vaccine-induced vasculitis most likely immune-mediated. Treatment consisted of aspirin and calcium channel blockers. Outcome was improvement. Author's conclusion: In spite of its widespread use, hepatitis B vaccination is uncommonly associated with adverse events. However, physicians should be aware of rare instances of small and medium vessel vasculitis. Patients should be informed of this rare potential side effect of Hepatitis B vaccination prior to administration. Physicians should be aware of Vaccination induced Raynaud's vasculitis in the differential diagnosis of a patient presenting with vasculitic symptoms.