Intended for healthcare professionals

Rapid response to:

Clinical Review

Influenza pandemics and avian flu

BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7524.1066 (Published 03 November 2005) Cite this as: BMJ 2005;331:1066

Rapid Response:

Flu vaccination and pancreatitis

Influenza vaccination is now routinely offered in the UK for all aged
65 years and over and all aged over 6 months in the following groups’ viz.
chronic respiratory disease, including asthma, chronic heart disease,
chronic renal disease, chronic liver disease, diabetes, immunosuppression,
those living in long-stay residential and nursing homes or other long-stay
facilities and those who are the main carer for an elderly or disabled
person1. It is generally well tolerated and recognised side effects
include soreness at the vaccination site, fever, malaise, myalgia, and
arthralgia. Immediate allergic reactions such as urticaria, angio-oedema,
bronchospasm, and anaphylaxis are rare.

We encountered an interesting case of a 51- year- old lady, who was
admitted to the surgical wards in October 2005 with a diagnosis of acute
pancreatitis without a definitive cause, which we would like to share. The
history and a serum amylase of 1427 u/l confirmed the diagnosis. She was
not known to have gallstones and denied any alcohol intake. Interestingly
she had been admitted around the same time in 2004 with a similar
diagnosis. She had a history of NIDDM and hypertension and her medications
at the time of the current admission included metformin, fenofibrate,
amlodipine and premarin. Investigations revealed a mildly high
triglyceride level (2.6mmol/L) and no other common causes of pancreatitis
were identified. The only consistent factor in the history seemed to be a
‘flu-jab’ approximately 10-15 days prior to each of the hospital
admissions. On obtaining further information from the patient’s general
practitioner, we found that she had a flu vaccination in 2003 uneventfully
but both the flu vaccinations in 2004 and 2005 were followed by an episode
of pancreatitis.

A literature review investigating an association was not very
informative. We found just one report of pancreatitis and cholestatic
hepatitis and pancreatitis associated with influenza virus vaccine2. We
did find documented evidence of acute pancreatitis associated with
measles, mumps and rubella (MMR) vaccination3,4, varicella vaccination5,
hepatitis A vaccination6 and typhoid and cholera vaccination7. Amongst the
recognised adverse effects of influenza vaccination were neuropathy8,
isolated hypoglossal nerve paralysis9, Guillain-Barre syndrome10,
relapsing encephalomyelitis11 and optic atrophy12. Since the
investigations did not reveal any significant biochemical or radiological
abnormalities that could be definitively identified as the cause for the
pancreatitis we believe considering the vaccination as associated with the
pancreatitis may be a possibility. That the probable mechanism of
causation could be immunologic in nature might explain why the patient did
not have the pancreatitis on the first occasion she had the jab.

Influenza vaccine is prepared each year using virus strains (which
are inactivated) recommended by the World Health Organization. Two types
of influenza vaccine are currently available in the UK; split virus and
surface antigen vaccine1. These are equally effective and have a similar
adverse reaction rate. A live attenuated influenza vaccine is also
produced, but is not licensed in the UK. Influenza immunization provides
protection against strains related to those in the vaccine for about 1
year and should be repeated annually. Given the recent concerns about bird
flu and an increase in the vaccination rate this rare association might be
worth keeping in mind.

REFERENCES:

1. Department of Health. The Influenza Immunisation Programme. London: DH,
2005. (PL/CMO/2005/2).

2. Influenza virus vaccine: Pancreatitis and cholestatic hepatitis: Case
report. Reactions 1993;1:9.
http://www.ingentaconnect.com/content/adis/rea/1993/00000001/00000480/ar...

3. Adler-J-B, Mazzotta-S-A, Barkin-J-S. Pancreatitis caused by measles,
mumps, and rubella vaccine. Pancreas 1991;6:489-490.

4. Feldman-G, Zer-M. Infantile acute pancreatitis after mumps vaccination
simulating an acute abdomen. Pediatr-Surg-Int 2000;16:488-89.

5. Chan-P-W, Goh-A-Y. Life threatening pancreatitis following varicella
vaccination: cause, association or co-incidence? Med-J-Malaysia
2000;55:527-8.

6. Haviv-Y-S, Sharkia-M, Galun-E, Safadi-R. Pancreatitis following
hepatitis A vaccination. Eur-J-Med-Res 2000;5:229-230.

7. Gatt-D-T. Pancreatitis following monovalent typhoid and cholera
vaccinations. Br-J-Clin-Pract 1986;40:300-301.

8. Furlow TW Jr. Neuropathy after influenza vaccination. Lancet.
1977;29:253-4.

9. Felix JK, Schwartz RH, Myers GJ. Isolated hypoglossal nerve paralysis
following influenza vaccination. Am J Dis Child. 1976;130:82-3.

10. Morris JA, Young BG. Guillain-Barre syndrome. Lancet. 1978;16:636.

11. Yahr MD, Lobo-Antunes J. Relapsing encephalomyelitis following the use
of influenza vaccine. Arch Neurol. 1972;27:182-3.

12. Macoul KL. Bilateral optic nerve atrophy and blindness following
swine influenza vaccination. Ann Ophthalmol. 1982;14:398-9.

Competing interests:
None declared

Editorial note
The patient whose case is described has given her signed informed consent to publication.

Competing interests: No competing interests

17 February 2006
Nitin Mukerji
Basic Surgical Trainee
Trivikram Garud, Reem Hasan, Fintan G. Bergin
Royal Victoria Infirmary, Newcastle-upon-Tyne, NE1 4LP