Should a patient with a history of swollen eye and tight throat after a flu shot receive a repeat influenza (flu) vaccination in the same season?

Management of Patient with Swollen Eye and Tight Throat After Flu Shot

A patient with a history of swollen eye and tight throat after a flu vaccination should not receive a repeat influenza vaccination in the same season, as these symptoms suggest a possible IgE-mediated hypersensitivity reaction that could lead to more severe outcomes with re-exposure. 1

Assessment of Reaction Type

The symptoms described (swollen eye and tight throat) require careful evaluation to determine the nature of the reaction:

1. Possible IgE-mediated hypersensitivity:

   • Swelling of the face/eyes and throat tightness are concerning symptoms that may represent an allergic reaction
   • These symptoms differ from Oculorespiratory Syndrome (ORS), which typically presents with bilateral red eyes, mild facial swelling, and respiratory symptoms 1

2. Distinguishing from ORS:

   • ORS is generally considered non-IgE mediated 1
   • ORS symptoms are typically mild and resolve within 24 hours 1
   • Throat tightness suggests potential airway involvement, which is more concerning than typical ORS

Decision Algorithm

Step 1: Evaluate severity of previous reaction

• Concerning signs of IgE-mediated hypersensitivity:
  • Throat tightness (potential airway involvement)
  • Facial/eye swelling
  • Timing of symptom onset (immediate reactions are more concerning)

Step 2: Determine appropriate action based on reaction assessment

• If signs suggest possible anaphylaxis or IgE-mediated reaction:

  • Do not administer repeat vaccination in the same season 1
  • Refer to allergist/immunologist for evaluation 1
  • Consider alternative prevention strategies

• If reaction is determined to be mild ORS without signs of hypersensitivity:

  • Revaccination may be considered under close medical supervision 1

Alternative Prevention Strategies

For patients who cannot receive repeat influenza vaccination:

1. Antiviral prophylaxis:

   • The CDC recommends antiviral medications as an alternative for preventing influenza among persons who cannot receive vaccination 1, 2
   • Oseltamivir (Tamiflu) 75mg twice daily for 5 days can be used for treatment if influenza develops 2

2. Infection prevention measures:

   • Hand hygiene
   • Avoiding close contact with ill individuals
   • Wearing masks in high-risk settings

Important Considerations and Caveats

• Allergist consultation: Patients with symptoms suggesting possible IgE-mediated hypersensitivity should be evaluated by an allergist before receiving any future influenza vaccines 1

• Future vaccination options: If future vaccination is deemed necessary by an allergist:

  • Consider cell culture-based (ccIIV) or recombinant (RIV) influenza vaccines for patients with severe allergic reactions to egg-based vaccines 2
  • Vaccination should occur in medical settings with supervision 2

• Risk-benefit analysis: While annual influenza vaccination is generally recommended for all people six months and older 3, the risk of a potentially severe allergic reaction outweighs the benefits of repeat vaccination in the same season for patients with previous concerning reactions

• Documentation: The reaction should be thoroughly documented to guide future vaccination decisions

Conclusion

The presence of swollen eye and tight throat after influenza vaccination suggests a possible allergic reaction that warrants caution. The Advisory Committee on Immunization Practices (ACIP) clearly states that persons with symptoms of possible IgE-mediated hypersensitivity after receipt of influenza vaccine should not receive influenza vaccination unless hypersensitivity is ruled out or revaccination is administered under close medical supervision 1.