Age: 12.0
Sex: F
Vaccine: HEP
Symptoms: Cerebellar syndrome, Glomerulonephritis, Haematuria, Hypoproteinaemia, Laboratory test abnormal
Clinical narrative: Two weeks after receiving a 1st dose of Hep-B vaccine, this girl developed hematuria which disappeared in 24 to 48 hours. This episode of hematuria was not documented with laboratory parameters. Two weeks after receiving the 2nd dose of the same recombinant Hep-B vaccine, this girl developed again hematuria. Subsequently, she was hospitalized. The physician exam was unremarkable. Because of persistent microscopic hematuria and proteinuria, a renal biopsy was performed and showed a mesangial proliferative glomerulonephritis with a generalized increase of mesangial cells and matrix, glomerular capillary wall thickening and, in some areas, IgA deposits in the mesangium. Immunohistological exam showed a strongly positive response only for HBsAg, localized in the tubular and peritubular areas. In the 9 first months of follow-up, further investigations showed a slow but progressive improvement of IgG concentration from 293 to 787mg/dl despite a mild hypoproteinemia (6g/l) and persistent proteinuria (2g/24h). Two years later, chronic glomerulonephritis persisted with microscopic hematuria and proteinuria that was controlled with Benazepril 10mg/day and ranging between 500 and 700mg/24h. The renal disease improved and complete remission was documented 3.5 years after dx. In the discussion of the above referenced article, it is mentioned that "in this case, a clear temporal association was present between HBV vaccine administration and the start of hematuria. In addition a renal biopsy was performed in our pt and demonstrated mesangial proliferative glomerulonephritis with IgA deposits, similar to that described in HBV-related glomerulonephritis. HBsAg was identified in renal tissue and in the tubular and peritubular zones. The low serum concentration of anti-HBsAg antibodies and the presence of circulating immune complexes might be a result of the tubular sediment consisting of immune complexes as has been shown in natural infection. The absence of HBsAg in the glomerula in a disease that affects them can be interpreted as a result of either too small a renal sample with few glomerula (only 3) that could be examined for HBsAg or faster clearance of immunocomplexes in glomerula than in the tubules. Although it is not possible to prove the causal link between our observation and the immunization, the time and the presence of the antigen in the renal biopsy are compelling. The absence of new episodes of hematuria because immunization is consistent with an association between vaccination and renal disease". *F/UP report on 9/23/02: Info has been received from an MD concerning a 24 mt old male w/no known drug allergies and no prior medical history who on 3/25/02 was vax'd IM w/1 dose of Hep A virus inactivated. There were no concomitant medications and no illness at the time of vax. W/in days, the PT experienced "significant neurological impairment". The MD noted that he considered hospitalizing the PT. The PT sought medical attention. F/UP info from the MD noted that the PT was a healthy, normal child w/no neurological SXs who was immunized w/the vax to go on vax w/his family. W/in 5 hrs post-vax, the PT became unsteady on his feet. His condition worsened and w/in 3 days he had developed ataxia. The child became totally disabled and was unable to speak, eat or walk. The PT was hospitalized and had a work up was done. He has 2 magnetic resonance imaging, a CAT scan and some genetic testing. All of the tests were normal. The PT did have eligoclonal bands, which were producing antibodies w/in the central nervous system. The PT was treated w/intravenous immunoglobulins to clear the antibodies. He was seen 1 wk after discharge from the hospital and was showing some mild improvement. The MD reported that he has sent blood and spinal fluid for PCR analysis for Hep A. He reported that he hopes that the condition is self-limited and that it will run the course and the child will recover. On 9/9/02, add'l f/up info was received from the MD starting that the PT has severe acute cerebellar ataxia. The PT has completely lost the ability to feed himself and to walk. He has fallen and broken arm due to the ataxia. The PT had been admitted twice to the hospital for IVIG TXs. The PT's events were considered to be disabling. Add'l info has been requested. The follow up received on 12/19/02 states additional follow-up info from the physician stating that the pt's medical condition was improving. The child was now feeding himself, walking 10-20 steps, and sleeping through the night. The physician also reported that he was "very comfortable with the pt's diagnosis of cerebellar ataxia, based on the clinical findings and that the ataxia was far out of proportion to the other symptoms. Ruling against a diagnosis of encephalitis are the results of the pt's tests including the fact that his CSF was negative, and an elevation in the oligoclonal bands."  The physician feels that this case is vaccine related. On 12/20/02, it was reported that there was an insufficient amount of specimen to receive results of the PCR analysis for hep A. The pt's events were considered to be disabling. Additional info is not expected.