(Chest. 2000;117:1803-1805.)
© 2000
American College of Chest Physicians
Symptomatic Pericarditis After Influenza Vaccination*
Report of Two Cases
Antoine de Meester, MD;
Raymond Luwaert, MD and
Jean-Marie Chaudron, MD
*
From the Department of Cardiology, Jolimont Hospital, Haine-Saint-Paul, Belgium.
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Abstract
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The authors report two cases of benign acute pericarditis after
the patients received vaccinations against influenza virus. The
diagnoses were confirmed by serologic changes and by the findings of
12-lead electrocardiogram and echocardiography. Symptoms and clinical
status improved on aspirin therapy. The authors underline the possible
mechanisms of this rare complication of influenza
vaccination.
Key Words: benign acute pericarditis • influenza virus • vaccination
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Introduction
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The
frequency of the administration of vaccination against influenza virus
increases in patients at risk, as recommanded by the Immunization
Practices Advisory Commitee in 1990. Vaccination is usually
well-tolerated. Benign local or general reactions, like fever or
myalgia, are frequently encountered. More rarely, systemic vasculitis
or other immunologic diseases have been observed.1
We
describe two cases of benign acute pericarditis occurring after
influenza vaccination, which probably were caused by an immunologic
systemic mechanism. Other such rare cases are reviewed.
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Case Reports
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Case 1
A 75-year-old man was admitted for fever, shivering, arthralgia,
and chest pain that increased with deep breathing. His medical history
included chronic renal insufficiency after undergoing a left
nephrectomy for a neoplasm 10 years ago, diabetes mellitus, and
cigarette smoking. No problem of allergy was ever encontered. The
symptoms developed only 6 days after he received vaccination for
influenza (Vaxigrip; Pasteur Merieux MSD; Brussels, Belgium).
Clinical examination was normal, except for a temperature of 38°C
that was recorded on three occasions. No precordial friction rub was
heard. The results of a 12-lead ECG were also normal. The laboratory
investigations on admission showed the following results: WBC count,
16,220/mm3 with a differential of 92% neutrophils;
C-reactive protein, 13.2 mg/dL; and a normal chemistry profile except
for creatinine, 2.6 mg/dL. The results of rheumatoid factor test was
negative. The results of serology tests for other viruses, including
hepatitis A, hepatitis B, cytomegalovirus, mononucleosis,
Coxsackievirus, and echovirus were negative. A chest roentgenogram
showed enlargement of the cardiac silhouette. An echocardiogram
revealed a small pericardial effusion, without any signs of tamponade
(Fig 1
). Pericardiocentesis was not performed at that time. The patient was
treated with aspirin, 1 g tid, for 1 month. Clinical improvement was
observed after a few days. The patient was discharged after receiving
aspirin for 10 days. After 30 days, echocardiography showed a complete
disappearance of the pericardial effusion, and aspirin was
discontinued.
Case 2
A 40-year-old man was referred from another hospital for
coronary angiography. He was a current smoker and had
hypercholesterolemia. His medical history included a recent peptic
ulcer. Two days before admission, the patient suffered from
intermittent acute chest pain that was not pleuritic or positional in
nature. Pertinent physical examination revealed the following results:
BP, 140/80 mm Hg; pulse rate, 100 beats/min; and temperature, 37.5°C.
The heart sounds were distant. No cardiac or pleural rubs were heard.
Twelve-lead ECG showed normal sinus rhythm, PR segments that were
clearly depressed, and ST segments that were elevated (Fig 2
). A diagnosis of acute myocardial infarction was suspected. The patient
was transferred for coronary angiography and primary percutaneous
transluminal coronary angioplasty. The results of echocardiography
and chest roentgenogram were normal. Initial laboratory data
revealed a negative troponin T test, an abnormal WBC count of
12,500/mm3, and an erythrocyte sedimentation rate of 50
mm/h. Urgent angiography was performed and showed healthy coronary
arteries. Left ventricular systolic function was also normal. The next
morning, a clear pericardial friction rub was heard. Thereafter, the
diagnosis of acute pericarditis was made. The patient afterwards
acknowleged having received a vaccination against influenza 5
days earlier. On the second day of hospitalization, repeat
echocardiography was unchanged. The patient was discharged on the third
day after admission and was prescribed aspirin to be taken orally.
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Discussion
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Influenza infection is a common viral illness. It appears every
year, infects the respiratory tract, and is responsible for
considerable morbidity and mortality, especially in COPD patients, the
elderly, or immunosuppressed patients. Common features of influenza
virus include fever, myalgia, cough, sneezing, sore throat, pneumonia,
asthma, and bronchitis. Neurologic complications reported are
convulsions neuritis, Guillain-Barré syndrome, encephalitis, and
coma.2
Myocarditis is a rare cardiac complication, but it occasionally
progresses to congestive cardiac failure and death.1
3
4
Benign acute pericarditis is even more rare. The viral origin is
suggested by a history of ongoing infection, typical chest pain, the
audible friction rub, the course of ECG changes, and possible
pericardial effusion. The diagnosis is supported by a significant rise
of antibodies against influenza virus.
Only a few cases of pericarditis after vaccination have been published
in the literature. In 1981, Streifler et al5
described the
first case of recurrent pericarditis after influenza vaccination. In
1997, Desson and colleagues6
described a similar case in a
40-year-old patient. At that time, the Centre National de
Pharmacovigilance in France reported four cases of pericarditis after
influenza vaccination. Other sporadic observations of pericarditis were
also described after vaccination against hepatitis B, yellow fever, and
smallpox.7
8
9
In 1977, Bloth and Lundman10
described a case of pleuroperimyocarditis caused by immunization with
bacterial anticatarrh vaccine, with circulating immune complexes in the
patient’s serum. Such bacterial vaccine etiology had not previously
been described. In any case, the reason that the vaccination is the
suspected cause relates to the chronology of the complication, as well
of the resolution, and the fact that no other viral causes were
encountered. In the previous reports, the vaccine antigens were not
even found in the patient’s serum. The hypothetical mechanisms of
immunologic systemic reactivity were not proven because of the rarity
of the disease. All cases were described after a first injection of the
influenza vaccine. A provocative test should probably help us to find
the real mechanisms for this rare illness. For ethical reasons, such a
test has not been performed.
In conclusion, such cases of patients with pericarditis after influenza
vaccination are rare, but the true incidences of the illness are
probably underestimated. However, this complication does not outweigh
the beneficial effects of the influenza vaccination in patients at
risk.
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Footnotes
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Correspondance to: A. de Meester, MD, Jolimont Hospital, 7100
Haine-Saint-Paul, Belgium
Received for publication August 3, 1999.
Accepted for publication November 18, 1999.
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References
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Margolis, KL, Poland, GA, Nichol, KL, et al (1990) Frequency of adverse reactions after influenza vaccination. Am J Med 88,27-30[Medline]
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Nicholson, KG (1992) Clinical features of influenza. Semin Respir Infect 7,26-37[Medline]
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Ray, CG, Icenogle, TB, Minnich, LL, et al (1989) The use of intravenous ribavirin to treat influenza virus-associated acute myocarditis. J Infect Dis 159,829-836[ISI][Medline]
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Fairley, CK, Ryan, M, Wall, PG, et al (1996) The organism reported to cause infective myocarditis and pericarditis in England and Wales. J Infect 32,223-225[CrossRef][ISI][Medline]
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Streifler, JJ, Dux, S, Garty, M, et al (1981) Recurrent pericarditis: a rare complication of influenza vaccination. BMJ 283,526-527
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Desson, JF, Leprevost, M, Vabret, F, et al (1997) Péricardite aigue bénigne après vaccination antigrippale. Presse Med 26,415
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Robinson, J, Brigden, W (1968) Recurrent pericarditis. BMJ 2,272-275
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Bensaid, J, Denis, F (1993) Péricardite aigue benigne après vaccination contre l’hépatite B. Presse Med 22,269
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Peyrière, H, Hillaire-Buys, D, Pons, M, et al (1997) Acute pericarditis after vaccination against hepatitis B: a rare effect to be known. Rev Med Interne 18,675-676
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Bloth, B, Lundman, T (1977) Pleuroperimyocarditis caused by immunization with anticatarrh vaccine. Acta Med Scand 201,137-140[Medline]
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Abstract
Introduction
