Cushing's syndrome induced by medroxyprogesterone.

Drs STEPHEN J ROGERSON and FRED J NYE (Fazakerley Hospital, Liverpool L9 7AL) write: Side effects of hepatitis B vaccine are rare but include erythema nodosum'l3 and uveitis.4 Polyarthritis has also been suggested in a Danish patient' and two other patients, whose adverse reactions are on file with the Committee on Safety of Medicines; arthralgia may be commoner. These are all symptoms of immune complex disease and suggest a possible aetiological link with the vaccine. A serum sickness-like illness due to circulating immune complexes occurs in 10-20% of patients with acute hepatitis B infection. We describe a patient who developed erythema nodosum and polyarthritis after the first dose of recombinant hepatitis B vaccine. In May 1989 a 31 year old man was given a standard 20 [tg dose ofEngerix B vaccine. The next day he developed pain in the metacarpophalangeal and proximal interphalangeal joints of both hands and painful wrists, hips, elbows, knees, ankles, and sacroiliac joints with swelling, most notably of both ankles. He also noted tender, raised, purplish skin lesions with a red margin on the left shin, which lasted a few days and were consistent in appearance with erythema nodosum. He had no history of arthritis, eye or chest disease, or related problems and no evidence of intercurrent infection. He was taking no drugs. By the time of our review he had only mild stiffness of the ankles with slight swelling of the right ankle. He had a normal full blood count and erythrocyte sedimentation rate and results of chest radiography, urine analysis, and microscopy; values for antinuclear factor and rheumatoid factor, titres of antistreptolysin 0 and brucella, serum IgE concentrations, and results of screening for HLA B27 were also normal. Hepatitis B surface antigen and IgG and IgM core antibodies were not detectable. The results of biochemical tests were normal apart from mildly elevated alkaline phosphatase (175 IU/1, range 30-130) and yglutamyltransferase (157 IU/1, 0-50) activities. Erythema nodosum lasted for one week, but the arthritis persisted for six weeks and was initially severely incapacitating. The patient was subsequently free ofsymptoms for nine months. He was unwilling to receive further vaccination in view of the low perceived risk of hepatitis B infection and the possible risk of further arthritis. Although it was not justifiable to rechallenge our patient, the similarity of his arthritis to that of acute viral hepatitis and its temporal relation to his hepatitis B vaccination, with the associated erythema nodosum, suggest an aetiological link with hepatitis B vaccine.