12/14/2012
I've recently seen a 58-year-old female patient with SLE and fibromyalgia who came in complaining of having had a reaction to the influenza vaccine 20 years ago. Her reaction began approximately 24 hours after administration and consisted of mostly gastrointestinal upset, and at 48 hours she noted a very significant worsening of her symptoms. She is not clear on whether or not she had fever, arthralgias, or myalgias and she denies having had respiratory symptoms. She went to the ER where blood testing revealed a "tremendously" elevated eosinophil count but no other information is available regarding other blood work done that day. She was not admitted but was evaluated by GI who reportedly ruled out a parasitic infection and no cause was found. She remained "very" sick for 3 weeks before her symptoms abated. She has never had another episode of eosinophilia or another similar GI episode. She denies having traveled anywhere prior to the occurrence of this episode and no one around her (as much as she can remember) had similar symptoms.

I am unsure as to how to proceed as this was a possible "delayed" reaction to what was probably a live attenuated virus vaccine that is no longer available. I surely cannot rule out the fact that an unrelated medical problem occurred and there are no records available for me to review. She and her other physicians would like her to receive a flu shot as she is maintained on Cellcept, and really, just because she should. Please advise. Thank you.

Thank you for your inquiry.

Unfortunately, there is no either in vivo or in vitro mechanism by which you can assess whether or not your patient can take influenza vaccine other than an actual challenge. Therefore, the decision becomes one of risk/benefit analysis, and there is no definitive answer.

In my opinion, the reaction you described would be very unusual after the administration of influenza vaccine, and I believe it is more plausible that there was another cause. Since influenza vaccine is desirable in her case, again, in my opinion, the benefit of a challenge outweighs the potential risk. However, I would do a graded challenge, and suggest the following format:

Administer 0.01 cc of the vaccine, and observe for 24 hours. If there is no reaction, administer 0.1 cc of the vaccine and observe for another 24 hours. Again, if there is no reaction, administer 0.2 cc, and observe for another 48 hours. If there is no reaction after the 0.2 cc dose, give the remainder of the therapeutic dose (0.3 cc).

Thank you again for your inquiry and we hope this response is helpful to you.

Sincerely,
Phil Lieberman, M.D.