Initial case was retrieved from the scientific literature on 09 February 2012. Verbatim from the published article: "INFLUENZA vaccination is a common annual event among individuals. Complications, although infrequent, are usually mild and self-limiting. This article describes the case of a 46-year-old man who experienced progressive osteolysis and surface chondrolysis of the proximal humerus following routine influenza vaccination. The patient presented with shoulder pain and limited range of motion 3 weeks following vaccination in the deltoid area. No skin changes were noted, inflammatory markers were normal, and the patient's pain and disability persisted despite nonsteroidal anti-inflammatory drugs and occupational therapy. Plain radiographs revealed a small lytic area involving the greater tuberosity of the humeral head. Magnetic resonance imaging (MRI) showed abnormal uptake and cystic changes involving the greater tuberosity of the humeral head; repeat MRI at 5 months showed progression in the cystic changes. Diagnostic arthroscopy of the shoulder revealed a hyperemic joint capsule and extensive, full thickness chondrolysis of the humeral head. Cystic biopsy demonstrated inflammatory cells and granulation tissue, consistent with foreign body response. Cultures were negative. Surgical debridement of the cystic areas and resurfacing of the humeral head yielded a good outcome. To our knowledge, this is the first reported complication of INFLUENZA vaccination requiring surgical intervention. Physicians need to be aware of the potential for osteolysis and chondrolysis, which may require aggressive forms of management." A 46 year-old male patient with a history of an open Bankart repair 13 years prior in the left shoulder but had been asymptomatic prior to vaccination, had received with a one inch needle in the lateral and proximal position in the left deltoid an INFLUENZA vaccine (manufacturer, lot number, route and date of administration not reported) and "immediately" following vaccination (also reported that the event began a "few days following vaccination), the patient experienced localized left anterior shoulder pain and limited forward flexion and external and internal rotation. The patient had a positive O'Brien's and Speed's tests. A magnetic resonance imaging (MRI) revealed an abnormal uptake and cystic changes involving the greater tuberosity of the humeral head. The patient was treated conservatively over the next five months with nonsteroidal anti-inflammatory drugs (NSAIDS) and occupational therapy. The patient's left shoulder pain and disability worsened, and the patient was unable to complete normal activities of daily living. A follow-up evaluation revealed the patient continued to have tenderness over the biceps tendon and further limitation on internal rotation. A repeat MRI showed the greater tuberosity cyst was rapidly enlarging. The patient underwent a diagnostic arthroscopy and an open biopsy of the cystic area. The arthroscopy revealed hyperemia of the exposed subchondral bone. Pathological examination of the surgical specimens demonstrated inflammatory cells and granulation tissue, consistent with reactive disease or foreign-body response. The progression of the events was attributed to a reaction to a reaction following the vaccines which according to the author was most likely given intraosseously. The patient was also noted to have extensive humeral head chondrolysis and biceps tendonitis. The patient had additional surgical intervention that included resurfacing of the proximal humerous and biceps tenodesis. Postoperative treatments included narcotics, NSAIDS and physical therapy. At the patient's most recent follow-up which was greater than three years postoperatively, the patient had pain free range of motion, excellent alignment and had returned to all activities. The patient's outcome was not reported. Documents held by sender: none.