Age: 61.0
Sex: F
Vaccine: HIBV, PPV, TD, HIBV, PPV, TD
Symptoms: Oedema, Proteinuria, Renal failure, Renal tubular disorder, Skin ulcer
Clinical narrative: Information regarding Hib vaccine was received from a literature source, regarding a 61 year old female pt who received a dose on an unspecified date along with a dose of Pneumovax and TD. Five days after vaccination, the pt experienced minimal change disease, allergic reaction, mild active interstitial nephritis, and acute tubular injury. The pt has a past history of acute myeloid leukaemia and stem cell transplant (non myeloablative hematopoietic, 1 year prior to vaccination). Past therapies included an anthracycline, Cytarabine, Fludarabine Phosphate, Busulfan, Methotrexate, Rapamune (sirolimus tablet) and Tacrolimus. Indication for Hib vaccine was immunization. Product was administered on an unspecified date. Dose regimen was 1 dose 1 time per day. Additional suspect vaccines included Pneumovax and TD. Concomitant medications were not reported. On an unspecified date, the pt underwent nonmyeloablative hematopoietic stem cell transplantation HSCT. One year later, the pt received a dose of Hib vaccine along with other vaccines. On the same day, blood creatinine was 0.8 mg/dl. After five days, the pt began to experience fatigue and progressive weight gain. Fourteen days after immunization, the pt gained 10 kg and had generalized edema. On the same day, the pt has a blood creatinine of 3.4 mg/dl, hypoalbuminenia of 0.28 mg/l, proteinuria of 4+, and no hematuria. Examination of urinary sediment showed fine granular casts. The pt was hospitalized for kidney biopsy and further evaluation. A Doppler renal ultrasound showed normal sized kidneys, normal vascular flow, and no hydronephrosis. A 24 hour urine collection contained 14g of urine protein. Light microscopy of the kidney biopsy showed tubular injury and a mild, but diffuse, interstitial inflammatory infiltrate consisting of mononuclear cells and scattered eosinophils. Ultrastructural evaluation revealed severe injury of glomerular visceral epithelial cells, including microvillous degeneration and diffuse foot process effacement. The pt was diagnosed with minimal change disease (glomerulonephritis minimal lesion), mild active interstitial nephritis, and acute tubular injury (renal tubular disorder. Treatment included diuresis and oral prednisone. The proteinuria and acute renal failure resolved rapidly. Within 3 weeks of the renal biopsy, the pt developed mild chronic Graft versus host disease GVHD, characterized by mildly elevated transminases, dry eyes, and oral ulceration's. Steroids were tapered and then discontinued after 10 weeks. After 9 months, the pt remained in clinical remission from acute myeloid leukemia and the glomerulonephritis minimal lesion. The GVHD responded to topical steroids and the elevated transminases normalized. The authors reported that the MCD was associated with an allergic reaction (Hypersensitivity) to vaccination since symptoms began 5 days after vaccination, MCD had previously been associated with both vaccination and ESCT, and recent date indicated that MCD might be more common than previously thought in nonmyeloablative HSCT recipients. The authors concluded that simultaneous immunization with three different vaccines might have resulted in hyperstimulation of the recovering immune system, leading to dysregulated T lymphocyte activation and , subsequently MCD. No additional information was available at the time of this report. See attached literature article for additional information.