Age: 67.0
Sex: F
Vaccine: FLUX
Symptoms: Skin hyperpigmentation, Skin plaque
Clinical narrative: This literature case, initially received on 22-Oct-2018, reported by a physician and concerns a 67-year-old, elderly, female patient. On an unspecified date in the past (reported as 1 year prior), the patient was administered influenza vaccine and had experienced numerous hyperpigmented patches coalescing on the back, flanks and buttocks consistent with post inflammatory hyperpigmentation as a result of bullous eruption. Biopsy found vacuolar interface dermatitis with subepidermal vesicle formation, epidermal necrosis, marked pigment incontinence, and mild lymphoeosinophilic infiltrate. The patient had recovered after 7 days with topical clobetasol 0.05 percent ointment. The patient's current conditions included type 2 diabetes mellitus, hypertension, chronic obstructive pulmonary disease and coronary artery disease. On an unspecified date, the patient was administered influenza vaccine, (route of administration: intramuscular, dose, anatomical location, batch number, expiry date, trade name and manufacturer: not reported). On an unspecified date, 3 days after vaccination, the patient developed multiple 2.5 to 5 cm hyperpigmented patches and plaques with a peripheral rim of erythema, some with overlying flaccid bullae, located on her bilateral hips and lower back. New bullae continued to appear across her groin, lower back, buttocks, axillae, and abdomen over the subsequent days. Although a few oral erosions involving the hard palate and vermilion lips were present, there was no evidence of ocular or genital mucosal involvement. But there was complete sparing of the distal extremities including the palms and soles. It was reported that the patient presented with painful bullous eruption. The patient remained afebrile with a normal complete blood count and comprehensive metabolic panel. Biopsy showed vacuolar interface dermatitis with subepidermal vesicle formation, epidermal necrosis, marked pigment incontinence, and mild lymphoeosinophilic infiltrate. These findings were consistent with the biopsy results from 1 year prior with similar clinical presentation. On an unspecified date, the patient was hospitalized. Within 2 days of hospitalization, new lesions continued to appear, covering 15 percent of her total body surface area. The patient was transferred to the burn intensive care unit for aggressive wound care. The patient was treated with topical clobetasol ointment and oral prednisone taper for bullous eruption. She was discharged after 14 days in the burn intensive care unit, with complete resolution at 30 days (recovered). On an unspecified date, the patient had completely recovered from the events. The reporter reported that the patient's reproducible bullous eruption and supportive biopsy results after receiving the influenza vaccine were consistent with generalized bullous fixed drug eruption (GBFDE). Additionally, the patient had involvement of only one mucosal surface. The delayed onset of her eruption might have been related to intramuscular delivery of the offending drug. Progression despite initiation of oral prednisone warranted transfer to the burn intensive care unit where aggressive support prevented life-threatening fluid losses, electrolyte imbalances, and secondary infections. Further research into the pathophysiology and treatment are needed to reduce the morbidity and mortality of this condition. The reporter assessed the case as serious (hospitalization) and considered the event bullous eruption as related to the suspect vaccine.