A 67 y.o. woman presented with a rash, weakness and difficulty speaking one day after a flu shot.
What is in the differential? the rash is pruritic and did not respond to prednisone.
Our patient was diagnosed as dermatomyositis on skin biopsy. . Her clinical picture fits with dermatomyositis because of diffuse muscle weakness and hoarseness. While the rash developed on the day after the shot; the muscle weakness took two weeks to develop.
Dermatomyositis can be triggered by coxsackie B virus, enterovirus and parvovirus. Several drugs can also trigger dermatomyositis including: cyclophosphamide, penicillin, sulfonamides, isoniazid, statins and vaccines.
In dermatomyositis immune attack occurs in muscle areterioles causing ischemia and death of muscle fibers.
Can flu shots aggravate autoimmune diseases?
The influenza vaccine has been associated with autoimmune adverse events, most frequently the Guillain-Barre syndrome, but also microscopic polyangiitis and rheumatoid vasculitis in adults. It has also been linked to thrombotic thrombocytopenic purpura. Reports have demonstrated increased antiphospholipid antibodies even in healthy subjects. Studies have shown high titers of anti-Sm, and anti Ro six weeks after influenza vaccination.
While vaccination has been associated with Guillain-Barre syndrome; so has infection with viruses like influenza, Zika, and camphylobacter. The antibodies which fight infection are thought to be similar enough to nerve cell proteins to attack them as well . Demyelinating neuropathy results which causes progressive muscle weakness and paralysis in Guillan-Barre syndrome. The cause is not clearly understood. It is known that the peripheral nervous system is more vulnerable to immune attack than the central nervous system because the blood-nerve barrier is particularly leaky(compared to the blood-brain barrier) within the dorsal root ganglia and is absent at nerve terminals. Once inside the peripheral nerve macrophages activate B cells and plasma cells causing complement induced nerve cell damage.
Guillan-Barre can be rapidly progressive and cause respiratory insufficiency
Our patient was treated with methylprednisolone, azathipprine and hydroxychloropquine alternating day rituximab and IVIG. Her symptoms have resolved.
Dermatomyositis can be triggered by coxsackie B virus, enterovirus and parvovirus. Several drugs can also trigger dermatomyositis including: cyclophosphamide, penicillin, sulfonamides, isoniazid, statins and vaccines.
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