Age: 22.0
Sex: F
Vaccine: FLU3
Symptoms: Skeletal injury, Tendon rupture, Ultrasound scan abnormal, X-ray limb normal
Clinical narrative: Case number PHHY2013US002049, is an initial literature report received on 08 Jan 2013. In this article, the author discussed about a case with shoulder injury related to vaccine. This case refers to a 22-year-old female patient. She had no significant prior medical history and was in good health until she received the vaccination. She was vaccinated with seasonal flu vaccine (manufacturer and batch number: unknown) to her left deltoid in 2011. This vaccine was given by the trained medical technician who placed the vaccine "three fingers from the acromion (measured at 2.75 inches or approximately 7 centimeter) in the middle of deltoid followed by hubbing (inserting the needle to the depth of the plastic hub but not depressing surrounding skin). Medical technician used a 1-inch, 23-gauge needle for injecting the vaccine. She had shoulder pain at the administration site within two hours after vaccination. After a few weeks, she had progressive limitations of her range of motion of her left shoulder and increasing pain/acute shoulder pain (9 out of 10 on a pain scale). On examination, the patient had very limited range of motion and function ability and experienced pain with both active and passive range of motion. On an unspecified date, eight weeks after vaccination, MRI (Nuclear magnetic resonance imaging) showed joint effusion in the subacromial bursa, a longitudinal partial tear if the supraspinatus tendon, and a consistent bony contusion. After 9.5 weeks of vaccination, ultrasound imaging revealed a partial tear of the supraspinatus tendon as well as cortical irregularity on the superolateral humeral head at the point of injection. Plain radiographs were unremarkable. Due to her limited range of motion, the patient had an immediate referral to sports medicine and was referred for aggressive physical therapy. At eleven weeks after vaccination, she had significant improvement in pain (1 out of 10) at rest, reporting discomfort with use of the left shoulder but no limitations in function. Ultrasound images at this time demonstrated residual fluid at the supraspinatus with a consistent cortical irregularity. On follow-up (16 months after vaccination), she reported that her range of motion and strength continued to allow her to conduct all her desired daily activities. Hence author reported that, her reaction of shoulder injury was related to vaccine administration (SIRVA), likely due to injection of the influenza vaccine into the subacromial bursa. The current case had a previously unreported finding of persistent cortical irregularity, making a stronger case the inflammatory response of the vaccine as the pathogenic factor of SIRVA. A study of MRI deltoid fat pads by Lippert found that using 5/8-inch, 7/8-inch needles for intramuscular deltoid injections would cause some patients to experience over penetration, respectively. As per weight based vaccination technique, for this patient (with weight 54 kilograms) 1/2-inch needle is recommended, but1-inch needle was used for injection. This case serves as a catalyst for discussion regarding vaccination technique and the potential complications arising from vaccine over penetration.