Case: Friend or Foe? Double seropositive vasculitis after influenza vaccination
No significant medical or surgical history.
72-year-old Caucasian male
Patient had a 4-week history of malaise, myalgia, and fever.
Four weeks prior to this situation he had received an inactivated influenza vaccination in primary care; four days after the vaccination he became ill and visited his general practitioner on two separate occasions over a 14-day period.
He was first prescribed a course of co-amoxiclav for a presumed lower respiratory tract infection, followed by doxycycline. There was no hemoptysis, but hematuria was noted. He had no history of medication or family history and was characterized as a smoker.
His physical examination on admission was normal, showing elevated inflammatory markers, positive dip in urine (Blood 3 +, protein 2 +), and an urgent ultrasound revealed normal-sized kidneys with no evidence of obstruction.
However, it did show a large abdominal aortic aneurysm (AAA).
He then underwent a computed tomography aortogram showing a 7 cm intrarenal AAA. He was admitted to the renal ward, where his renal function continued to deteriorate despite administration of 768 micromoles/L peak creatinine.
An urgent immunological test showed positive ANCA with 74 U/ml MPO antibodies and positive anti-GBM with 53 U/ml antibodies, so he was started on hemodialysis via temporary vascularization and was given high-dose intravenous methylprednisolone (500 mg) for two consecutive days.
Three days later he was induced with oral cyclophosphamide (100 mg) before beginning seven plasma exchanges over ten days and starting "cyclocross". This is with induction/integration therapy using pulsed cyclophosphamide for AAV. During her hospitalization, she was dependent on dialysis treatment and was treated to continue intermittent dialysis upon discharge. An early decision was made to postpone the AAA intervention until the vasculitis treatment was complete.
The patient was then discharged and continued to receive cyclophosphamide as an outpatient, demonstrating good renal recovery after treatment. (Creatinine 321 μmol/L)
Benjamin Norton, Suiping Kong, Rammis Perera, Richard Hull, Vaccines: friend or foe? Double Seropositive Vasculitis After Influenza Vaccination, Oxford Medical Case Reports, Volume 2019, Issue 5, May 2019, omz031, https: //doi.org/10.1093/omcr/omz031
What we can learn from this case
The patient was positive for both myeloperoxidase antineutrophil cytoplasmic and anti-glomerular basement membrane antibodies.
The patient had stage 3 acute kidney injury requiring dialysis.
She is being treated with methylprednisolone, intravenous cyclophosphamide and plasma exchange.
He had an incidental 7 cm abdominal aortic aneurysm.
With the recovery of renal function, he achieved remission and was no longer associated with hemodialysis.
Although causality cannot be proven, it is hypothesized that the transient association between influenza vaccination and double seropositive vasculitis directly triggered a systemic immune response in a susceptible patient.This was the first case of double seropositive vasculitis occurring in temporal association with seasonal influenza vaccination.
