Septic Arthritis of the Glenohumeral Joint Following Influenza Vaccination

Case Report and Review of the Literature

James E. Darnley, MD; Joseph A. Rosenbaum, MD; Grant L. Jones, MD; Julie Y. Bishop, MD

Disclosures

Curr Orthop Pract. 2019;30(5):495-497. 

In This Article

Discussion

Many different types of shoulder injuries after vaccine administration have been packaged by governing agencies into a single term, known as SIRVA (Shoulder Injury Related to Vaccine Administration). It is important to raise awareness to SIRVAs, especially in the field of orthopaedic surgery due to the potential complications that could occur. We report a case of prolonged shoulder pain after a vaccine that was discovered to be septic arthritis and a rotator cuff tear with the intention of improving the awareness of potentially severe adverse effects of improper vaccine administration among the orthopaedic community.

The Centers for Disease Control and Prevention (CDC) lists shoulder pain as a common symptom following influenza vaccination[1] and estimates that it may be as high as 90% with other vaccines[2] without going into specifics regarding the details of the pathology. Simple injection site pain and true glenohumeral joint pain are not always differentiated in these studies. Therefore, some orthopaedic surgeons might not take post-vaccine pain seriously, as the incidence of more severe joint injuries is presumed to be much lower.

There are several previous reports of SIRVAs[3–6] but none featuring a true septic arthritis. Atanasoff et al.[7] reported 13 cases of SIRVAs, of which four required surgery, and none of which were caused by a presumed septic shoulder. A case series with three patients who had frozen shoulder following vaccine administration has been previously reported.[8] Finally, a 22-year-old presented with pain immediately after a vaccine and was eventually diagnosed with a partially torn rotator cuff.[9]

Our patient was a 32-year-old healthy woman with an intact immune system. She had no ongoing infections or risk factors for a joint infection. There was no previous trauma or procedure to the affected shoulder. Her pain started soon after the injection and never resolved prior to presentation. Due to a lack of another cause and the time course in which her symptoms began, we believe that the vaccine caused an indolent infection. The vaccine was the inciting event that caused the infection and the subsequent complications.

The current literature shows several similar presentations after a vaccine, but no true cases of septic arthritis. A 59-year-old woman presented to the emergency department with erythema and edema after a pneumococcal vaccination.[10] She had an elevated C-reactive protein and erythrocyte sedimentation rate and a clinical presentation that was concerning for septic arthritis. Upon surgical debridement and culture of joint fluid, it was determined that no infection was present. McColgan et al.[11] described a similar case of a pseudoseptic arthritis in a 74-year-old woman after a pneumococcal vaccination. She presented 5 hours after vaccine administration for pain and limited range of motion. Joint aspiration was concerning for septic arthritis but was not diagnostic. After 2 days of antibiotics, she was taken to the operating room for diagnostic arthroscopy. Ultimately, it was determined there was no infection. Both cases had negative Gram stains and cultures that showed no growth. Likewise, there was no purulent joint fluid that was noted. Both patients had evidence of a rotator cuff tear.

Our patient was significantly younger, previously healthy, and had a less acute presentation compared to the previously reported cases. There were no findings on physical examination that were suggestive of an infection on initial presentation. A positive Gram stain is a unique finding from what has been previously reported in the literature. The rotator cuff tear seen in our 32-year-old patient was likely due to the infection and not a chronic degenerative tear. The prolonged course of antibiotic treatment and C. difficile makes for a more severe case than previously reported.

Our case demonstrates the importance of a diagnostic work-up in a patient presenting with shoulder pain after a vaccine. Shoulder pain after a vaccination could often have a benign presentation. However, as the case shows, serious consequences, including medical and financial, can occur. Without the proper work-up and monitoring for symptom resolution, a serious complication with long-term ramifications could be missed.

The health benefits of vaccines vastly outweigh the risks associated with them, but they are not completely without risk. It is our goal to help recognize these rare but potentially severe complications early. Additional research in this area may help us to better understand the prevalence of vaccine-induced shoulder injuries and the exact etiology of rotator cuff tears in the setting of infection.

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