In the last years numerous reports describing a possible association between administration of vaccines and development of autoimmune phenomena and overt autoimmune disease were published. Possible mechanisms of induction of autoimmune phenomena by vaccines and their excipients are probably similar to those implicated in induction by infectious agents. Here we report the case of an 11-year-old girl who developed autoimmune hepatitis type II after four weeks from vaccination against human papillomavirus. The possible relationships between the use of adjuvated vaccine against papillomavirus and autoimmune hepatitis are discussed. Although we do not provide evidence for a causal link, we suggest that the occurrence of the autoimmune hepatitis may be related to the stimulation of immune system by adjuvated-vaccine, that could have triggered the disease in a genetically predisposed individual. Therefore a monitoring of liver function test following administration of vaccine against papillomavirus may be useful in adolescent girl with signs of hepatopathy, as jaundice, dark urine or hepatomegaly, to early identify and to promptly treat autoimmune liver disorders.

Autoimmune reaction after vaccination is sporadically reported in the medical literature. Vaccinations are generally safe and have an important role in eradicating endemic diseases worldwide. Nevertheless, the question arises as to whether there is a possibility of post-vaccination autoimmune phenomena. The anti-tetanus vaccine is being used since 1924, and it is part of the recommended immunization schedules for children. There are few reports of autoimmune diseases, such as rheumatoid arthritis and anti-phospholipid syndrome after anti-tetanus vaccination. Herein, we describe four cases, of which we believe, show a clear temporal relation between anti-tetanus vaccination and the appearance of dermatomyositis, systemic lupus erythematosus, type 1 diabetes mellitus and anti-phospholipid syndrome. We also suggest some of the pathogenic mechanisms that promote a pathogenic autoimmune response.

OBJECTIVES:In this study we analyzed the clinical and demographic manifestations among patients diagnosed with immune/autoimmune-mediated diseases post-hepatitis B vaccination. We aimed to find common denominators for all patients, regardless of different diagnosed diseases, as well as the correlation to the criteria of Autoimmune (Auto-inflammatory) Syndrome induced by Adjuvants (ASIA).

PATIENTS AND METHODS:We have retrospectively analyzed the medical records of 114 patients, from different centers in the USA, diagnosed with immune-mediated diseases following immunization with hepatitis-B vaccine (HBVv). All patients in this cohort sought legal consultation. Of these, 93/114 patients diagnosed with disease before applying for legal consultation were included in the study. All medical records were evaluated for demographics, medical history, number of vaccine doses, peri-immunization adverse events and clinical manifestations of diseases. In addition, available blood tests, imaging results, treatments and outcomes were recorded. Signs and symptoms of the different immune-mediated diseases were grouped according to the organ or system involved. ASIA criteria were applied to all patients.

RESULTS:The mean age of 93 patients was 26.5± 15 years; 69.2% were female and 21% were considered autoimmune susceptible. The mean latency period from the last dose of HBVv and onset of symptoms was 43.2 days. Of note, 47% of patients continued with the immunization program despite experiencing adverse events. Manifestations that were commonly reported included neuro-psychiatric (70%), fatigue (42%) mucocutaneous (30%), musculoskeletal (59%) and gastrointestinal (50%) complaints. Elevated titers of autoantibodies were documented in 80% of sera tested. In this cohort 80/93 patients (86%), comprising 57/59 (96%) adults and 23/34 (68%) children, fulfilled the required criteria for ASIA.

CONCLUSIONS:Common clinical characteristics were observed among 93 patients diagnosed with immune-mediated conditions post-HBVv, suggesting a common denominator in these diseases. In addition, risk factors such as history of autoimmune diseases and the appearance of adverse event(s) during immunization may serve to predict the risk of post-immunization diseases. The ASIA criteria were found to be very useful among adults with post-vaccination events. The application of the ASIA criteria to pediatric populations requires further study.

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Kawasaki disease (KD) is an acute, self-limited, systemic vasculitis of unknown aetiology, extremely rare in infants younger than 6 months old. Younger infants are more likely to present with incomplete KD (IKD) and are at higher risk of developing coronary abnormalities. An early and specific clinical sign, not included in the classical diagnosis criteria, but that can be very useful in the diagnosis of KD, is the reaction at the Bacillus Calmette-Guérin (BCG) inoculation site. We describe a case of a 4-month-old boy, fully immunised, whose BCG scar reactivation led to the diagnosis of IKD. This case-report emphasises the importance of BCG site reactivation in establishing a diagnosis of IKD that clinicians should be aware of, especially in countries where BCG vaccination is still part of the immunisation schedule.

A patient with basal-cell epithelioma occurring in a smallpox vaccination site is reported. The association is probably not a chance occurrence.

A 52 year old housewife was vaccinated against smallpox at the age of 18, on her right deltoid area. At the age of 50 she noticed erythema and scaling on the vaccination scar and 2 years later a nodule appear that enlarged during the following 3 months. There was no history nor skin changes suggestive of significant sun exposure. The histological examination of an initial biopsy and of the subsequently excised lesion revealed a basal cell carcinoma of the solid type. The relevant literature was reviewed and discussed with emphasis on sex and age incidence, age and site of vaccination, free interval between inoculation and tumor appearance, coexistence or not of other sun induced neoplasias and precancerous lesions and other possibly relevant clinical and etiopathogenetic aspects.

Mycobacterial Spindle cell Pseudotumor (MSP) is a rare complication of mycobacterial infection, especially the atypical variety. It is characterized by an exuberant spindle cell proliferation. This has been reported in the lymph nodes, skin, spleen, lungs, brain, etc. The incidence is higher in immuno-compromised patients, especially those with acquired immunodeficiency syndrome. It is rare to encounter this lesion in infants. We report a case of MSP in the axillary lymph node of a 7-month-old infant, following Bacillus Calmette Guerin (BCG) vaccination due to Mycobacterium tuberculosis complex, which was proved by PCR.

Current European League Against Rheumatism guidelines strongly recommend considering the use of polysaccharide pneumococcal vaccine in all patients with autoimmune inflammatory rheumatic diseases. However, a previously published case series reports of reactions to 23-valent pneumococcal polysaccharide vaccine in patients with Behcet's disease. The purpose of this report is to present a similar case of a systemic adverse reaction in a patient with Behcet's disease to 23-valent pneumococcal polysaccharide vaccine.

Bell's Palsy is the sudden onset of unilateral temporary paralysis of facial muscles resulting from seventh cranial nerve dysfunction. Presented here is a two-year old female patient with right peripheral facial palsy following hepatitis B vaccination. Readers' attention is drawn to an uncommon cause of Bell's Palsy, as a rare complication of hepatitis B vaccination.

We report about hirudotherapy in a patient with chronic complex regional pain syndrome (CRPS) in the right hand. CRPS is a multifactorial disease associated with disabling pain as well as sensory and motor deficits. The optimal therapeutic management is based on personalized multimodal treatment approaches; however, hirudotherapy has not been described in the available literature. To date, we have completed five medicinal leech treatments. Altogether, hirudotherapy led to rapid and substantial relief of symptoms, especially with respect to pain intensity ratings and skin temperature asymmetries. In addition, the patient's active and passive agility of the affected limb improved obviously.

Benign recurrent abducens nerve palsy is rare. Twenty-three cases in children have been reported in the literature and many of these cases followed immunization or were associated with viral illness. Most of the reported patients share the following features: spontaneous recovery within 6 months, ipsilateral recurrence, and painless palsy. The authors describe a Turkish child with recurrent abducens nerve palsy with no obvious etiology.

The association between sudden infant death syndrome and immunization is frequently discussed. Serious adverse events following vaccination have generally been defined as those adverse events that result in permanent disability, hospitalization or prolongation of hospitalization, life threatening illness, congenital anomaly or death. They are generally referred to the inherent properties of the vaccine (vaccine reaction) or some error in the immunization process (programme error). The event could also be totally unrelated but only temporally linked to immunization (coincidental event). A fatal case of a 3-month-old female infant, who died within 24 h of vaccination with hexavalent vaccine is presented. Clinical data, post-mortem findings (acute pulmonary oedema, acute pulmonary emphysema), quali-quantitative data collected from immunohistochemical staining (degranulating mast cells) and laboratory analysis with a high level of beta-tryptase in serum, 43.3 microg/l, allows us to conclude that acute respiratory failure likely due to post hexavalent immunization-related shock was the cause of death.

The vaccination has much profit for an infectious disease. On the other hand, there is little frequency, side effects may appear. It includes severe complication. We reported the case that resulted in bilateral acute profound hearing loss after mumps alone and measles and rubella (MR) vaccination. The case was a 5 years old girl. She inoculated mumps alone and MR vaccine. After 18days later, both sides profound hearing loss occurred in her. The hearing loss was not improved by the intravenous feeding of the steroid. Three months later, cochlea implantation was carried out to her right ear. She got hearing again. As for the hearing loss, mumps vaccine was considered as a cause from a latency period until the onset. The bilateral profound hearing loss that was a very rare complication was occurred by vaccination. The care of the hearing is important, but the mental care of an affected child and the parent is important, too.

OBJECTIVE:We report a case of deafness occurring in a temporal context of an influenza vaccination in a 79-year-old woman.

METHODS:Case report and review of the literature on influenza causing deafness.

RESULTS:A 79-year-old woman with normal hearing developed acute bilateral sensorineural hearing loss two days after a seasonal influenza vaccination, other obvious reasons for acute hearing loss were excluded.

CONCLUSION:This patient appears to be the first reported case of bilateral deafness following a trivalent seasonal influenza vaccination.

A case of a 40-year old marine with bilateral optic neuritis and a branch retinal artery occlusion after vaccination is presented. Blood investigations showed no abnormalities. Cerebrospinal fluid studies revealed a lymphocytic pleocytosis and IgG antibodies against hepatitis A and rabies. Computerized tomography and magnetic resonance imaging of the brain were negative. A diagnosis of vaccine-induced auto-immune demyelinative optic neuritis was made. The clinical picture improved after systemic corticosteroid treatment.

BACKGROUND:Optic neuropathy is a rare adverse reaction to vaccination.

CASE REPORT:A 62-year-old-woman was hospitalized for bilateral optic neuropathy with loss of vision. The symptoms occurred 15 days after a seasonal influenza vaccination. Her past medical history included a mixed connective tissue disease with no immunosuppressive treatment for several years. Investigations did not reveal any obvious cause and the hypothesis of post-influenza vaccination bilateral optic neuropathy was retained although a complication of the connective tissue disease complication could not be ruled out. The patient was given intravenous methylprednisolone 1g daily. At a cumulative dose of 8 g, oral steroids were given and tapered off.

DISCUSSION:Few similar case reports have been described in literature. The causal link between vaccination and optic neuropathy thus remains to be confirmed. Clinicians should however consider this etiology.

Revaxis(®) is a vaccine against diphtheria, tetanus and poliomyelitis (dT-IPV). This vaccine should not be administered by the intradermal or intravenous route. Poor injection techniques and related consequences are rare. We report a case of bursitis associated with reactive glenohumeral effusion complicated by bone erosion occurring after injection of the dT-IPV vaccine. A 26 year old patient was admitted for painful left shoulder causing functional impairment. Control magnetic resonance imaging showed bone oedema on the upper outer part of the humeral head, with a slight cortical irregularity, indicating that the vaccine was injected in contact with the bone at this location, causing erosion. Outcome was favourable after intra-articular corticosteroids. Reports of articular or periarticular injury after vaccination are extremely rare, in view of the substantial number of vaccines administeredevery year. The potential complications of vaccination are well known to general practitioners but under-reported in the literature.

CASE REPORT: A 29-year-old wheelchair-bound woman was presented to us by the gastroenterologist with suspected osteomalacia. She had lived in the Netherlands all her life and was born of Moroccan parents. Her medical history revealed iron deficiency, growth retardation, and celiac disease, for which she was put on a gluten-free diet. She had progressive bone pain since 2 years, difficulty with walking, and about 15 kg weight loss. She had a short stature, scoliosis, and pronounced kyphosis of the spine and poor condition of her teeth. Laboratory results showed hypocalcemia, an immeasurable serum 25-hydroxyvitamin D level, and elevated parathyroid hormone and alkaline phosphatase levels. Spinal radiographs showed unsharp, low contrast vertebrae. Bone mineral density measurement at the lumbar spine and hip showed a T-score of -6.0 and -6.5, respectively. A bone scintigraphy showed multiple hotspots in ribs, sternum, mandible, and long bones. A duodenal biopsy revealed villous atrophy (Marsh 3C) and positive antibodies against endomysium, transglutaminase, and gliadin, compatible with active celiac disease. A bone biopsy showed severe osteomalacia but normal bone volume. She was treated with calcium intravenously and later orally. Furthermore, she was treated with high oral doses of vitamin D and a gluten-free diet. After a few weeks of treatment, her bone pain decreased, and her muscle strength improved.

DISCUSSION: In this article, the pathophysiology and occurrence of osteomalacia as a complication of celiac disease are discussed. Low bone mineral density can point to osteomalacia as well as osteoporosis.

Borderline tuberculoid leprosy was diagnosed clinically and histologically in a four year-old boy about 6 months after intradermal vaccination with BCG. His mother reported that a lesion began to appear above the vaccination site on the arm 2 weeks after the vaccination, and a second lesion appeared on the chin 2 months later. Responses in the lymphocyte transformation test to sonicated Mycobacterium leprae, BCG, and to PPD were consistent with a tuberculoid leprosy infection. Precipitation of BT leprosy by intradermal BCG infection may possibly represent the overcoming of a phase of primary suppression in an individual who might otherwise have progressed toward lepromatous leprosy. The implications of this hypothesis for the planning of a controlled trial of an anti-leprosy vaccine are discussed.