Short communicationAtraumatic osteonecrosis of the humeral head after influenza A-(H1N1) v-2009 vaccination
Introduction
In spring 2009, the emergence of the new influenza type A-(H1N1) virus initiated a pandemic with a rapid global extension within a few months. Initial observations of increased mortality rates and of unusually high rates of severe complications of infected persons in Mexico and the United States led to a worldwide vaccination campaign as recommended by the World Health Organization and governmental authorities of several countries [1]. New vaccine formulations needed to be manufactured within a relatively short time. Some of them contained adjuvants to enhance the immune response in conjunction with an antigen-sparing effect in the presence of limited manufacturing capacities [2], [3], [4].
Mainly in Germany, the adjuvanted split-virus vaccine Pandemrix™ (GlaxoSmithKline) containing a relatively novel oil-in-water emulsion (AS03) was used for influenza A-(H1N1) v-2009 vaccination. Confirming previous tests with the new adjuvant [5], [6], [7], surveillance reports described more intense local reactions and increased rates of mild general symptoms, as compared with seasonal influenza vaccines [8], [9], [10], [11], [12]. But those surveillance reports found no increase in the frequency of rare, severe adverse effects such as anaphylactic reactions, neurologic complications, or vasculitis.
Here we report the occurrence of a single case of atraumatic osteonecrosis of the humeral head after an influenza A-(H1N1) v-2009 vaccination with the AS03 adjuvanted vaccine. To the best of our knowledge, osteonecrosis has never been associated with any form of vaccination. Although the available data cannot establish a causal relationship, our patients clinical course suggests a pathogenetic link between vaccination and osteonecrosis. The purpose of our report is to increase awareness of this severe event as a possible, exceptional side effect of parenteral influenza vaccination.
Section snippets
The clinical case
In November 2009, a 48-year-old female physician without previous disease underwent an influenza A-(H1N1) v-2009 vaccination with Pandemrix™ (A81CA061A, GlaxoSmithKline) by a single injection into the anterolateral portion of the deltoid muscle of the left arm. About 2½ h after vaccination a pronounced and painful local swelling with redness and hardening of the skin and deeper tissue layers developed at the injection site. Within the next 4 weeks, the swelling and redness slowly declined but
Discussion
Osteonecrosis is a well-known complication of severe, proximal bone injuries; according to current pathogenetic concepts it is due to an interruption of the local blood supply of the affected bone [13]. Its atraumatic form is associated with a variety of conditions, including long-term corticoid administration, alcohol abuse, hemoglobinopathies, dysbarism, and immune disorders such as connective tissue disease and vasculitis [14], [15]. The precise pathogenesis remains obscure, and a
Conclusion
Considering the millions of persons [10] who have been vaccinated with adjuvanted vaccines, humeral osteonecrosis – if induced by vaccination in our patient – has to be considered an exceptional event. Therefore, its occurrence does not alter the relation between benefits and risks of the recent pandemic vaccination campaign. Yet because of its clinical course which is characterized by the insidious and delayed onset of nonspecific shoulder symptoms, it is possible that mild forms previously
Acknowledgement
We thank Mary Knatterud, Ph.D., Associate Professor, Department of Surgery, College of Medicine, University of Arizona, for helpful comments and editorial assistance.
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2020, VaccineCitation Excerpt :Similar findings have been previously described in case reports of shoulder injury following vaccination [16,20]. Although less common, bone edema and necrosis was also evident among our cases, which has also been reported in the literature [8,21]. A general clinical or radiographic finding among our cases was evidence of injury to internal structures, primarily, but not limited to, the tendons of the rotator cuff and bursae.
Rapid Progressive Osteonecrosis of the Humeral Head After Arthroscopic Rotator Cuff Surgery
2018, Arthroscopy - Journal of Arthroscopic and Related SurgeryRisk of bursitis and other injuries and dysfunctions of the shoulder following vaccinations
2017, VaccineCitation Excerpt :This can induce an intense immune and inflammatory response in the shoulder capsule [34–37]. This, in turn, would cause injuries and dysfunctions, like edema, erosion, and even necrosis of the humeral head [8,10,17,19,38]. In our study, we noted that shoulder injuries and dysfunctions following vaccination were most frequent with the influenza vaccine compared with the rest of vaccines, probably because the former is given to the highest number of patients.