Report of Superficial and Deep Vein thrombosis following Influenza ...

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International Journal of Internal Medicine Papers

International Journal Of Internal Medicine Papers 2018; ; 3 (1): 1-3

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Report of Superficial and Deep Vein thrombosis following Influenza Vaccination in Lower and Upper Extremities Seyed Mohammad Hosseininejad1, Ali Mirabi2, Mir Saeid Ramezani1, Amir Shamshirian3, Samira Hosseini3, Seyed Hossein Montazer*1 1. Emergency Department, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, Iran. 2. Medical Student, Student Research committee, Mazandaran university of Medical Sciences, Sari, Iran. 3. Department of Laboratory Sciences, School of Allied Medical Science, Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran.

Abstract Influenza is a contagious respiratory tract infection, which is most commonly mild and self-limited. Receiving the influenza vaccine can decreases the incidence of influenza and the risk of influenza-related complications. However, the influenza vaccine is safe, serious complications may develop in rare cases. There is not any distinct study witch represent deep vein thrombosis as a complication of influenza vaccine. We would like to report on a case of VTE following influenza vaccination in a 35-year-old male presented with edema, tenderness and erythema of left and right lower extremities and left upper extremity and subjective feeling of fever or chills. Key words: Vein thrombosis, Influenza, Vaccination, Iran Citation to This Article: Hosseininejad SM, Montazer SH, Ramezani MS, Mirabi A, Shamshirian A, Hosseini S. Report of Superficial and Deep Vein thrombosis following influenza vaccination in lower and upper extremities. International Journal Of Internal Medicine Papers 2018; 3 (1): 1-3

1. Introduction Venous thromboembolism (VTE) includes deep vein thrombosis (DVT) and pulmonary embolism (PE) witch have an estimated annual incidence of about 2.5 per 1000 person-years. Research has shown that there is a higher risk of VTE following influenza-like illness (1, 2). The risk of VTE, increases noticeable after age 50 years (3). Known risk factors for VTE include malignancy, traumatic injury or surgery, hypertension, metabolic disorders, hormone therapy, smoking (4). There are small numbers of studies on the possible association between respiratory tract infections following influenza virus with the occurrence of VTE. Influenza vaccination has potential to decrease the risk of cardiovascular events in patients with coronary heart disease, but its impact on the risk of VTE has not been studied (5, 6). There is not any distinct study witch represent deep vein thrombosis as a complication of influenza vaccine. We would like to report on a case of VTE on left lower and upper limbs following influenza vaccination and this is the first report of DVT following influenza vaccination. * Corresponding author: Seyed Hossein Montazer [email protected]

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2. Case Report A 35-year-old male presented with edema, tenderness and erythema of left and right lower extremities and left upper extremity. He had no complain of nausea, vomiting, shortness of breath, constipation, rhinorrhea, diarrhea, headache, dizziness. He has subjective feeling of fever or chills. He had received the seasonal influenza vaccine about two months before admission to the hospital. The day after influenza vaccination, the patient had backache and cramps of lower extremities and left upper extremity. He did not mention any history of underling diseases such as diabetes, hypertension or pulmonary diseases. He is not smoker or opium addict. Allergy history to food or drug was negative. The vital signs at the time of admission were including blood pressure=120/80 mmHg, pulse rate= 15, respiratory rate= 76 and temperature= 37.8 °c (oral). The patient was consciousness, oriented to time, place and person and was not in ill or toxic condition. In physical examination, there were erythema, tenderness, non-pitting edema and pruritus in both right and left sides of lower extremities and erythema, tenderness, non-pitting edema in the left upper extremity. Other physical features were normal. The laboratory tests, which were taken at the hospital, are as following below: In complete blood count (CBC) analysis: RBC (red blood count): 4.6 x 106, HCT (hematocrit): 40.9%, HGB (hemoglobin): 14.1 g/dl, PLT (platelet): 303000, WBC (white blood count): 14100, PMN (polymorphonuclear): 66.9%, LYM (lymphocyte): 27.5%, MID (group everything that is not either a neutrophil or a lymphocyte): 5.6%. In biochemistry analysis: Creatinine (Cr): 1.1 mg/dl, Urea: 21 mg/dl, Glucose: 90 mg/dl, Na (sodium): 140 mEq/L, K (potassium): 5.6 mEq/L. In ABG (atrial blood gas): pH: 7.27, pCO2: 57 mmHg, HCO3-: 26.2 mmol/L In Doppler ultrasonography of both sides of lower extremities and left upper extremity, all common femoral vein (CFV), superficial femoral vein (SFV) and popliteal vein in both left and right lower extremities were open, compressible, with normal venous flow and there was no evidence of acute deep vein thrombosis. The augmentation of the left lower extremity of popliteal vein was decreased. The anterior and posterior tibialis veins and lesser saphen vein were dilated, non-compressible and contains clot without vascular flow. The compressibility of dorsalis pedis veins were decreased with lack of venous flow. In left upper extremity Doppler ultrasonography, axillary vein was open, compressible, with normal venous flow and there was no evidence of clot. Proximal to distal part of one of the brachial veins and basilica vein were dilated, non-compressible, echogenous and without obvious vascular flow. Total above evidences in Doppler ultrasonography suggests SVT in lesser saphen, DVT in distal part of mentioned veins of both left and right lower extremities, SVT in basilica vein and DVT in one of the brachial veins in left upper extremity (Fig. 1).

Figure 1. Vein thrombosis (dilated and non-compressible lesser saphen vein without vascular flow) in color Doppler ultrasonography showed with white arrow.

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3. Discussion Vaccinations are recommended throughout one’s life to provide protection against diseases. Influenza vaccination is recommended for all adults each year, other adult vaccinations are recommended for particular individuals based on age, medical conditions, behavioral risk factors, job or travel conditions (7). Influenza is a seasonal, contagious respiratory illness that is mostly mild and self-limited, although occasional severe manifestations may lead to hospitalization and even death. Although the influenza vaccine is relatively safe and effective, serious complications can develop in rare cases (8). Many risk factors of VTE have been well established, including genetic predisposition, immobilization, surgery, pregnancy, oral contraceptives (OCP) and cancers (9-11). A complete blood count reveled mild leukocytosis with normal WBC differentiation, blood chemistry showed no abnormality. However, here the patient develop venous thromboembolism in the absence of one of these risk factors.in these case presentation, the patient grow evidence of deep vein thrombosis approximately after two months injection of influenza vaccine. There is no previous study witch represent DVT as a complication of influenza vaccine and this case presentation is the first report of DVT following influenza vaccination. 4. Conclusion Our findings suggest that clinicians should be aware of the possibility of interstitial pneumonia as a complication of the influenza vaccine, ask closed questions about vaccination in medical interviews, and educate patients about this complication, as these will facilitate early detection and treatment. Although the safety of this vaccine has been confirmed, relatively newer drugs warrant further investigation to confirm their association with interstitial pneumonia. References 1. Clayton TC, Gaskin M, Meade TW. Recent respiratory infection and risk of venous thromboembolism: case– control study through a general practice database. International journal of epidemiology. 2011;40(3):819-27. 2. van Wissen M, Keller TT, Ronkes B, Gerdes VE, Zaaijer HL, van Gorp EC, et al. Influenza infection and risk of acute pulmonary embolism. Thrombosis journal. 2007;5(1):16. 3. Fowkes F, Price J, Fowkes F. Incidence of diagnosed deep vein thrombosis in the general population: systematic review. European Journal of Vascular and Endovascular Surgery. 2003;25(1):1-5. 4. Goldhaber SZ. Venous thromboembolism: epidemiology and magnitude of the problem. Best Practice & Research Clinical Haematology. 2012;25(3):235-42. 5. Zhu T, Carcaillon L, Martinez I, Cambou J-P, Kyndt X, Guillot K, et al. Association of influenza vaccination with reduced risk of venous thromboembolism. Thrombosis and haemostasis. 2009;102(6):1259-64. 6. Schmidt M, Horvath‐ Puho E, Thomsen RW, Smeeth L, Sørensen HT. Acute infections and venous thromboembolism. Journal of internal medicine. 2012;271(6):608-18. 7. Williams WW, Lu P-J, O'Halloran A, Bridges CB, Kim DK, Pilishvili T, et al. Vaccination coverage among adults, excluding influenza vaccination-United States, 2013. MMWR Morbidity and mortality weekly report. 2015;64(4):95-102. 8. Hibino M, Kondo T. Interstitial Pneumonia Associated with the Influenza Vaccine: A Report of Two Cases. Internal Medicine. 2017;56(2):197-201. 9. Holst AG, Jensen G, Prescott E. Risk factors for venous thromboembolism. Circulation. 2010;121(17):1896-903. 10. Suchon P, Al Frouh F, Henneuse A, Ibrahim M, Brunet D, Barthet M-C, et al. Risk factors for venous thromboembolism in women under combined oral contraceptive. Thrombosis and haemostasis. 2016;115(1):13542. 11. Martinelli I, De Stefano V, Mannucci PM. Inherited risk factors for venous thromboembolism. Nature Reviews Cardiology. 2014;11(3):140-56.

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