Objective:

To describe recurrent type II mixed cryoglobulinemic vasculitis occurring after influenza vaccination.

Approach:

• Case: An 83-year-old man developed bilateral lower-extremity purpura and acute kidney injury on two occasions, each about one week after influenza vaccination.
• Evaluation: Skin biopsy showed leukocytoclastic vasculitis; cryoprecipitate immunofixation demonstrated monoclonal IgM and polyclonal IgG. Extensive evaluation for infectious, autoimmune, hematologic, and malignant causes did not identify an etiology.
• Follow-up: The second episode included transient PR3-ANCA positivity and more severe acute kidney injury. Renal biopsy, obtained approximately one year after the second hospitalization, showed acute tubular injury and diabetic glomerulosclerosis, without immune complex–mediated glomerular disease or ANCA-associated crescentic glomerulonephritis.

Key Findings:

• Both episodes occurred one week after influenza vaccination; extensive evaluation did not identify an etiology.
• After the second episode, the rash and serologic abnormalities resolved, but kidney function did not return to baseline.
• Renal function stabilized at a new baseline creatinine of approximately 2.0–2.4 mg/dL.

Interpretation:

The authors state that recurrence after vaccination twice, with no alternative etiology identified, suggests a causal relationship. They also propose that a preexisting low-level clonal B-cell population may have been present, with vaccination acting as an immunologic trigger rather than causing the disease. The mechanism remains unclear.

Limitations:

• A low-level B-cell clone could not be excluded.
• Renal biopsy was substantially delayed, occurring approximately one year after the second hospitalization.

Conclusion:

The authors state that vaccine-associated vasculitis should be considered when typical causes of mixed cryoglobulinemic vasculitis have been excluded.

Sources:

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