Case Reports in Rheumatology
Volume 2012 (2012), Article ID 785028, 3 pages
http://dx.doi.org/10.1155/2012/785028
Case Report
Rheumatoid Arthritis and Swine Influenza Vaccine: A Case Report
Gurjot Basra,1 Praveen Jajoria,2 and Emilio Gonzalez2
1Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX 77555, USA
2Division of Rheumatology, University of Texas Medical Branch, Galveston, TX 77555, USA
Received 3 April 2012; Accepted 15 June 2012
Academic Editors: D. Aeberli, J. V. Dunne, and F. Schiavon
Copyright © 2012 Gurjot Basra et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Rheumatoid arthritis (RA) is the most common chronic inflammatory joint disease. Multiple scientific articles have documented that vaccinations for influenza, MMR, and HBV, to name a few, could be triggers of RA in genetically predisposed individuals. However, there is limited data regarding the association of swine flu vaccine (H1N1) and RA. We report the case of a Mexican American female who developed RA right after vaccination with H1N1 vaccine. Genetically, RA has consistently been associated with an epitope in the third hypervariable region of the HLA-DR chains, known as the “shared epitope”, which is found primarily in DR4 and DR1 regions. The presence of HLA-DRB1 alleles is associated with susceptibility to RA in Mexican Americans. Hence, certain individuals with the presence of the “shared epitope” may develop RA following specific vaccinations. To our knowledge, this is the first reported case of RA following vaccination with the swine flu vaccine.
1. Introduction
Rheumatoid arthritis (RA) is the most frequent of all chronic inflammatory joint diseases characterized by pain, swelling, stiffness, and destruction of joints due to synovial inflammation and effusion resulting in disability. It affects 0.5–1% of population in industrialized world with annual incidence reported to be around 12–1200 per 100,000 [1]. Women are affected two to three times as often as men and peak age of onset is between the ages 30 and 55 but can occur at any age. The etiology of RA is multifactorial and includes hormonal, environmental, genetic, infectious, and other variables. RA is associated with the presence of an epitope in the third hypervariable region of the HLA-DR β chains, known as the “shared epitope." Individuals with the sequence leu-glu-lys-arg-ala in residues 67–74 have a much higher incidence of developing RA [2]. This sequence is found in DR4, DR14, and DR1 β chains. HLA-DRB1 allele is associated with susceptibility to RA in Mexican Americans while HLA-DRB1*08 appears to have a protective influence on RA susceptibility and disease severity in Mexican Americans.
It has been shown that the onset of rheumatic disease after vaccination signifies that the vaccine may trigger persistent autoimmune response in genetically predisposed individuals. Vaccinations that are suspected to cause RA include influenza, MMR, HBV, tetanus toxoid, typhoid, paratyphoid A and B (TAB), polio, diphtheria, and small pox [3]. HLA DR-4 was frequently present in the above-described patients, suggesting that genetically susceptible individuals are at increased risk for RA after vaccinations. However, there is no causal association between swine flu vaccination and RA onset that has been documented so far. We report a case of Mexican American female who develops RA after vaccination (H1N1) exposure which could possibly be due to her genetic susceptibly explained by above factors.
2. Case Report
A 33-year-old Hispanic female with no significant past medical history was referred to the rheumatology clinic in May 2010 by her primary care physician for having pain and swelling in multiple joints since November 2009. Patient received a seasonal flu shot in October and a week later, she noted some joint pain and aches in hands, wrists, and knees, which resolved within a few days and patient became asymptomatic. A month later, she received H1N1 (swine influenza) vaccine and a week after started experiencing joint pain, swelling, and stiffness in hand, wrist, elbow, shoulder, and knee joints. She also complained of significant morning stiffness that last for more than one hour. On physical examination she had bilateral synovitis in fourth and fifth metacarpophalangeal (MCP), second, and third proximal interphalangeal (PIP) joints, with prominent left ulnar styloid. She fulfilled most of the criteria for classification of RA based on American College of Rheumatology (ACR) guidelines.
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