Eastern Mediterranean Health Journal
Back | Back Issues | EMHJ home | EMRO homepage

Volume 13 No. 2  March - April , 2007		Print this article	PDF

Case report

Panuveitis and dermal vasculitis following MMR vaccination

M. Sedaghat,¹ S. Zarei-Ghanavati,¹ S. Shokoohi¹ and A. Ghasemi²

¹Khatam-Al-Anbia Eye Hospital, Mashad University of Medical Sciences, Mashhad, Islamic Republic of Iran (Correspondence to S. Zarei-Ghanavati: sizagh@yahoo.com). ²Ophthalmologist, Sabzevar, Islamic Republic of Iran. Received: 22/05/05; accepted: 27/07/05

 

Introduction

Although anterior uveitis and skin and visceral involvement has been reported in association with measles, mumps and rubella (MMR) vaccination [1–4], we are unaware of previous reports of panuveitis. In 2004, millions of Iranians were immunized with the live attenuated MMR vaccine during a mass vaccination project. We present a case of panuveitis and dermal vasculitis that developed shortly after MMR vaccination. The patient was diagnosed, investigated and followed up at the Khatam-al-Anbia eye centre, Mashad.

Case report

A previously healthy 17-year-old girl was admitted to Sabzevar hospital on 29 December 2003 due to a generalized maculopapular skin rash with fever and chills which developed 3 days after receiving the MMR vaccine. Her medical and ocular histories were unremarkable. Two days after hospitalization she complained of progressive visual loss, red eyes and pain. On ophthalmological examination best corrected vision was 6/10 in both eyes, tension by applanation tonometry was 14 mmHg in both eyes, biomicroscopy showed perilimbal ciliary flush, keratic precipitates and 3+ cells in the right eye and 4+ cells in the left eye with moderate flare in both eyes. Anterior uveitis was diagnosed and she received topical prednisolone acetate 1%, 6 times a day and cyclopentolate 1%, 4 times a day. Two days later her symptoms worsened in spite of the topical treatment. Best corrected vision was reduced to hand motion. Biomicroscopy revealed anterior uveitis with hypopyon and severe vitritis.

The patient was referred to Khatam-al-Anbia Eye Centre 4 days after first hospitalization and hospitalized again. On review, the patient was suffering from fever (oral temperature = 39 ºC), generalized maculopapular skin rash and knee arthritis (Figure 1).

Biomicroscopy disclosed severe ciliary injection in both eyes with keratic precipitates and posterior synechiae; the anterior chamber had severe reaction with 1 mm hypopyon and a severe flare. Severe vitritis was also present. The intraocular pressure was 10 mmHg in the right eye and 8 mmHg in the left eye. In both eyes, fundus examination with dilated pupil showed blurred disk margins with multiple cream-coloured lesions, deep in the retina. By fluorescein angiography, multiple areas of hyperfluorescence with late leakage were revealed in the posterior pole (Figure 2).

Skin biopsy showed dermal vasculitis (Figure 3).

Blood count showed leukocytosis and neutrophilia. Her C reactive protein and erythrocyte sedimentation rate were moderately elevated. The patient had a negative protein purified derivative (PPD) and VDRL. Antinuclear antibodies, rheumatoid factor, HLA-B5 and HLA-B27 were also negative. She had normal chest and sacroiliac joint radiographs. Angiotensin-converting enzyme level was normal. Urine examination did not reveal any abnormal finding. The patient was diagnosed with bilateral panuveitis and was given intravenous methylprednisolone, 1 g/day, in addition to topical medication. After 3 days of therapy, the anterior chamber reaction was reduced significantly (2+ cells and flare with no hypopyon). Vitritis was also moderately reduced. Visual acuity had corrected to 3/10 level and the skin rash had resolved partially with faint pigmentation.

The patient was discharged with oral prednisolone 1 mg/day in addition to topical prednisolone acetate 1%, 4 times a day and cyclopentolate 1%, 4 times a day. After 10 days, oral prednisolone was gradually reduced and then discontinued. Regular follow-up and adjustment of the corticosteroid eye drops led to complete control of uveitis after 1 month. At follow-up 6 months later, the patient was free of cells and aqueous flare and she returned to a corrected vision of 10/10 in the right eye; however, the best corrected vision in the left eye was reduced to 6/10. By slit lamp examination of the left eye, iris atrophy, posterior synechiae and posterior capsular cataract were identified (Figure 4).

Examination of the right eye showed no significant change. Intraocular pressure in both eyes was within the normal limit. Fundoscopy of both eyes was normal in spite of a vitreous band without any traction on the retina in the left eye (Figure 5).

Discussion

In our case, the severe bilateral panuveitis after MMR vaccination could have been due to various causes:

1. Immunization: Initial immunization may play a role in uveitis irrespective of the etiologic factor. Based on this reality, several models of uveitis have been developed for experimental purposes [5–9]. Retinal S antigen induced uveitis [5,6,9], interphotoreceptor retinoid binding protein induced uveitis [7,9], lipopolysaccharide [10] and lipoteicoic acid [11] induced uveitis are examples of such experimental animal models. In all these models, initial immunization is essential to induce inflammation. During immunization viral antigen or tissue culture products may also initiate the early events in the immune activation pathway to induce uveitis by antigen mimicry.

2. Other toxins or antigens: Contamination of the vaccine with other toxins or antigens or modification of the vaccine due to faulty preservation may play a role in the induction of uveitis.

3. Coincidence: Although the possibility of mere coincidence cannot be excluded, no signs or symptom of other causes were detected at the onset and during the 6 months of follow-up. It should be added that the patient had negative PPD and VDRL, antinuclear antibodies, rheumatoid factor, HLA-B5 and HLA-B27.

4. Viral uveitis: It is possible that the live attenuated viruses of the MMR vaccine caused uveitis. Mild anterior uveitis has been seen in several systemic viral diseases such as measles, influenza and rubella [12] but we could not find any report of panuveitis.

The clinical data suggest that the vaccine was a precipitating factor. Acute posterior multifocal placoid pigment epitheliopathy following hepatitis B vaccine [13], anterior uveitis following varicella vaccine [14] and 2 cases of anterior uveitis 4 and 6 weeks after combined MMR vaccination [1] have been reported.

We searched MEDLINE from 1966 to 2005 and the bibliography lists from retrieved articles but we were unable to find a similar case, especially post-vaccination panuveitis. To our knowledge, therefore, this is the first report of such an association.

In conclusion, panuveitis and dermal vasculitis may occur following MMR vaccination. Although most cases of adverse reactions to vaccination are mild, in exceptional cases there may be serious consequences such as panuveitis or uveitis that may result in permanent sequelae and visual loss. Our observations call for ophthalmic awareness after MMR vaccination cases when ocular symptoms develop. In the future closer monitoring of all cases of vaccination, especially those in adolescents, is advocated since early therapy is obviously important.

References

1. Islam SM, El-Sheikh HF, Tabbara KF. Anterior uveitis following combined vaccination for measles, mumps and rubella (MMR): a report of two cases. Acta ophthalmologica Scandinavica, 2000, 78:590–2.

2. Ozaki T et al. Henoch–Schonlein purpura after measles immunization. Acta paediatrica Japonica, 1989, 31:484–6.

3. Hanissian AS et al. Vasculitis and
   myositis secondary to rubella vaccination. Archives of neurology, 1973, 28:202–4.

4. MacDonald TT. Measles vaccination as a risk factor for inflammatory bowel disease. Lancet, 1995, 345(8961):1363, author reply 1364.

5. Nussenblatt RB. Experimental autoimmune uveitis: Mechanism of disease and clinical therapeutic indications. Investigative ophthalmology & visual science, 1991, 32:3131–41.

6. Nussenblatt RB et al. S Antigen uveitis in primates: A new model for human disease. Archives of ophthalmology, 1981, 99:1090–2.

7. Broekhuyse RM et al. Experimental autoimmune anterior uveitis (EAAU), a new form of experimental uveitis. Induction by detergent insoluble, intrinsic protein fraction of the retinal pigment epithelium. Experimental eye research, 1991, 52:465–74.

8. Mochizuki M et al. Effect of cyclosporine and other immunosuppressive drugs on experimental autoimmune uveoretinitis. Investigative ophthalmology & visual science, 1985, 26:226–32.

9. Wacker WB. Proctor Lecture. Experimental allergic uveitis. Investigations of retinal autoimmunity and the immunopathologic responses evoked. Investigative ophthalmology & visual science, 1991, 32:3119–28.

10. Nakamura S et al. The role of tumor necrosis factor alpha in induction of experimental autoimmune uveoretinitis. Investigative ophthalmology & visual science, 1994, 35:3884–9.

11. Charteris DG, Lightman SL. In vivo lymphokine production in experimental autoimmune uveoretinitis. Immunology, 1993, 78:387–92.

12. Rao NA et al. Basic and clinical science course Section 9: Intraocular inflammation and uveitis 2002–2003. San Francisco, Foundation of American Academy of Ophthalmology, 2003:144–148F.

13. Brezin AP et al. Acute posterior multifocal placoid pigment epitheliopathy after hepatitis B vaccine. Archives of ophthalmology, 1995, 113:297–300.

14. Esmaei B, Winkelman JZ. Uveitis associated with varicella virus vaccine. American journal of ophthalmology, 1999, 127:733–4.