HUMAN VACCINES & IMMUNOTHERAPEUTICS 2017, VOL. 13, NO. 3, 572–573 http://dx.doi.org/10.1080/21645515.2016.1235105
CASE REPORT
HSV2 reactivation and myelitis following influenza vaccination Allan Lieberman and Luke Curtis Center for Occupational and Environmental Medicine, North Charleston, SC, USA
ABSTRACT
ARTICLE HISTORY
We report the case of a 57 year-old woman who developed transverse myelitis and acute HSV-2 reactivation following influenza vaccination. Over the next 5 years, she experienced a fluctuating course of improvement and regression for both myelitis and herpes.
Received 22 August 2016 Revised 3 September 2016 Accepted 7 September 2016 KEYWORDS
herpes simplex virus 2 (HSV-2); influenza vaccination; myelitis
Introduction Herpesvirus 2 (HSV2) is a common chronic viral infection affecting about 16–22% of the adult US population.1,2 HSV-2 reactivation with adverse symptoms occurs in about 89% of people with primary HSV-2 infection with a median recurrence rate of about 4 per year.2 Although many infected individuals are asymptomatic, HSV-2 causes considerable morbidity in many individuals and can cause life threatening infections in neonates and those with compromised immune symptoms.1 HSV-2 viruses can remain latent in many nerves (especially the sacral nerves), and periodically flare up with viral shedding which may be asymptomatic or associated with symptoms.3,4 Many factors can increase the risk of HSV-2 reactivation such as stress, fatigue, sun exposure, surgery, infection, fever, and menstrual periods.5 A study of 457 consecutive patients with HSV-2 isolated from genital lesions reported that patients who had primary HSV-2 infections lasting 35 or more days had a recurrence rate 1.83 times greater than those who had shorter initial HSV-2 infections (mean 0.66 vs 0.36 recurrences month, p D 0.001).2 HSV-2 reactivation rates were also about 20% higher in men than women.2 This case report describes a 62 year-old woman who developed severe HSV-2 reactivation symptoms following influenza vaccination 5 y earlier.
Patient presentation The patient is a 62 year-old female of English/French/German descent. Her childhood was generally healthy with several childhood infections including varicella at age 8 years, measles at 9, and mumps at 10. Patient had herpes HSV-2 at 24 y of age with blisters on back lasting about 2 months. The patient had back surgery for herniated disk at age 25 y. She married at age 30 and had 2 healthy sons at age 31 and 34 y. At age 43, the patient reinjured her back and had head pressure which was CONTACT Luke Curtis, MD, MS, CIH 29407, USA. © 2017 Taylor & Francis
[email protected]
later diagnosed as pseudotumor cerebri. Also at age 43, she had ventriculoperitoneal shunts placed on left side to relieve pressure with some relief. At age 51, the patient went through menopause after losing 80 pounds on a low-carbohydrate diet. On October 15, 2010 (age 57) she received an influenza vaccination FluvirinÒ which contained 15 mg of hemagglutinin from each of 3 viruses A/California/7/2009, NYMC X-181 (H1N1), A/Victoria/210/2009, NYMC X-187 (H3N2), and B/ Brisbane/60/2008 plus thimerosal- 25 mg Hg per dose. Five hours after receiving flu shot she had “hot liquid fluid feeling” all over left side and her left side started vibrating severely. She developed 7 severe HSV-2 blisters on her back and many bouts of migraine headaches. Had swelling of left arm and legs, abnormal vibrations, and “pins and needles” most troubling on left side especially the left head, and fluttering sensations controlled by atenolol. Condition was later diagnosed as transverse myelitis. Had food poisoning on March 2011 with bad herpes blister breakout. A peripheral nerve conduction study on 6/27/11 was essentially normal apart from a slightly reduced right sural sensory amplitude. Seen by author (AL) first on 7/28/11. Physical exam was generally unremarkable except for wobbly Romberg, pressure and pain on left side- especially left brain region, also pain on medial portion of right leg. On 7/28/11 patient tested positive for neural antibodies to both central nervous system (CNS) (IgA+ IgG) myelin and peripheral nervous system (PNS) myelin (IgA & IgG). She was treated with a variety of drugs over varying periods of time including lorazepam (1 mg QPM PRN), interferon-a (1 ml of 150 U/ml 3 times a week), trazadone 50 mg QD, and low dose naltrexone (2.25 to 4.5 mg). Her HSV-2 titres (>1.09 considered positive) were as follows: 48.1 on 7/28/11, 5.93 on 1/11/12, 3.7 on 2/21/12, 3.56 on 7/25/12, 3.5 on 8/6/12, and 14.3 on 9/14/15. HSV-1 were negative (
CASE REPORT
HSV2 reactivation and myelitis following influenza vaccination Allan Lieberman and Luke Curtis Center for Occupational and Environmental Medicine, North Charleston, SC, USA
ABSTRACT
ARTICLE HISTORY
We report the case of a 57 year-old woman who developed transverse myelitis and acute HSV-2 reactivation following influenza vaccination. Over the next 5 years, she experienced a fluctuating course of improvement and regression for both myelitis and herpes.
Received 22 August 2016 Revised 3 September 2016 Accepted 7 September 2016 KEYWORDS
herpes simplex virus 2 (HSV-2); influenza vaccination; myelitis
Introduction Herpesvirus 2 (HSV2) is a common chronic viral infection affecting about 16–22% of the adult US population.1,2 HSV-2 reactivation with adverse symptoms occurs in about 89% of people with primary HSV-2 infection with a median recurrence rate of about 4 per year.2 Although many infected individuals are asymptomatic, HSV-2 causes considerable morbidity in many individuals and can cause life threatening infections in neonates and those with compromised immune symptoms.1 HSV-2 viruses can remain latent in many nerves (especially the sacral nerves), and periodically flare up with viral shedding which may be asymptomatic or associated with symptoms.3,4 Many factors can increase the risk of HSV-2 reactivation such as stress, fatigue, sun exposure, surgery, infection, fever, and menstrual periods.5 A study of 457 consecutive patients with HSV-2 isolated from genital lesions reported that patients who had primary HSV-2 infections lasting 35 or more days had a recurrence rate 1.83 times greater than those who had shorter initial HSV-2 infections (mean 0.66 vs 0.36 recurrences month, p D 0.001).2 HSV-2 reactivation rates were also about 20% higher in men than women.2 This case report describes a 62 year-old woman who developed severe HSV-2 reactivation symptoms following influenza vaccination 5 y earlier.
Patient presentation The patient is a 62 year-old female of English/French/German descent. Her childhood was generally healthy with several childhood infections including varicella at age 8 years, measles at 9, and mumps at 10. Patient had herpes HSV-2 at 24 y of age with blisters on back lasting about 2 months. The patient had back surgery for herniated disk at age 25 y. She married at age 30 and had 2 healthy sons at age 31 and 34 y. At age 43, the patient reinjured her back and had head pressure which was CONTACT Luke Curtis, MD, MS, CIH 29407, USA. © 2017 Taylor & Francis
[email protected]
later diagnosed as pseudotumor cerebri. Also at age 43, she had ventriculoperitoneal shunts placed on left side to relieve pressure with some relief. At age 51, the patient went through menopause after losing 80 pounds on a low-carbohydrate diet. On October 15, 2010 (age 57) she received an influenza vaccination FluvirinÒ which contained 15 mg of hemagglutinin from each of 3 viruses A/California/7/2009, NYMC X-181 (H1N1), A/Victoria/210/2009, NYMC X-187 (H3N2), and B/ Brisbane/60/2008 plus thimerosal- 25 mg Hg per dose. Five hours after receiving flu shot she had “hot liquid fluid feeling” all over left side and her left side started vibrating severely. She developed 7 severe HSV-2 blisters on her back and many bouts of migraine headaches. Had swelling of left arm and legs, abnormal vibrations, and “pins and needles” most troubling on left side especially the left head, and fluttering sensations controlled by atenolol. Condition was later diagnosed as transverse myelitis. Had food poisoning on March 2011 with bad herpes blister breakout. A peripheral nerve conduction study on 6/27/11 was essentially normal apart from a slightly reduced right sural sensory amplitude. Seen by author (AL) first on 7/28/11. Physical exam was generally unremarkable except for wobbly Romberg, pressure and pain on left side- especially left brain region, also pain on medial portion of right leg. On 7/28/11 patient tested positive for neural antibodies to both central nervous system (CNS) (IgA+ IgG) myelin and peripheral nervous system (PNS) myelin (IgA & IgG). She was treated with a variety of drugs over varying periods of time including lorazepam (1 mg QPM PRN), interferon-a (1 ml of 150 U/ml 3 times a week), trazadone 50 mg QD, and low dose naltrexone (2.25 to 4.5 mg). Her HSV-2 titres (>1.09 considered positive) were as follows: 48.1 on 7/28/11, 5.93 on 1/11/12, 3.7 on 2/21/12, 3.56 on 7/25/12, 3.5 on 8/6/12, and 14.3 on 9/14/15. HSV-1 were negative (
