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I have a 57 year-old white female who is followed for allergic rhinitis, post nasal drip, food allergies, and drug sensitivity (Codeine and Singulair.) She was percutaneously skin tested in 2015 for egg yolk and egg white because of GI symptoms related to these items. She was positive for both of these food proteins and began to avoid these in her diet at this time.

Because of this history, she was given Flucelvax QIV (without egg) in 2019. She developed a generalized erythematous papular rash over her abdomen in approximately 1.5 hours after vaccine administration. Previous year vaccines include Fluarix Quad in 2018 and Fluvirin PF in 2017 without reactions to either one. She was recently re-tested percutaneously for egg white and egg yolk with corresponding positive and negative controls. These were negative.

I need your guidance as to what vaccine she should be given for this year's flu season and should it be given in graded fashion? I have reviewed the PI for both of the 2018 and 2017 flu vaccines and they do vary in terms of preservatives, latex, etc. Also, should she be pre-treated with Prednisone and Benadryl prior to administration?


I asked Dr. John Kelso for his input. His response is as follows:

"The nature (maculopapular) and timing (1-1/2 hours after vaccine administration) of this patient's rash do not suggest an IgE mediated mechanism, although the timing suggests the vaccine was causal. There would not be any tests to prove this relationship nor to predict its recurrence. Assuming that the rash did not go on to involve other features suggestive of a severe cutaneous adverse reaction (SCAR), it would seem the benefits of repeat vaccination (protection from influenza disease) would outweigh the risks of a potential recurrence. The patient's egg allergy status is not a consideration for the receipt of egg-containing vaccines because they do not contain enough egg protein to cause reactions even in severely egg-allergic patients. The most recent guidance states that 'It is not necessary to inquire about egg allergy prior to the administration of any influenza vaccine, including on screening forms.' Thus, if the patient agrees with this risk-benefit analysis, I would recommend that she be vaccinated with a single dose of any other influenza vaccine than the one related to her reaction and be observed for 2 hours afterwards since this would include the timeframe of her original reaction. If no reaction occurred, in subsequent years, such observation would not be required."

Pre-treatment or graded doses would not be needed.

I hope this is helpful.

Daniel J. Jackson, MD, FAAAAI

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