Working Diagnosis:
Periosteal reaction secondary to influenza vaccination

Treatment:
The patient was given meloxicam and tramadol for pain control and advised to rest her arm when possible. She was instructed to notify the office if she developed a fever or any signs of systemic infection.

Outcome:
The patient's shoulder pain gradually improved. She was reevaluated five months post-injection and still had mild pain at the injection site. Repeat MRI was obtained at the time which showed decreased periosteal reaction compared with prior imaging.

Editor's Comments:
A periosteal bone reaction describes a radiographic finding that indicates there has been an insult to the bone. It can occur from any number of causes, including inflammatory arthritis, genetic conditions, fluorosis, hypervitaminosis A, osteomyelitis, malignancy, benign tumors, thyroid disease, fracture, stress fracture, and venous stasis. There are few case reports in the literature of an immunization causing a periosteal reaction, and most are associated with the BCG vaccine.

Various appearances on x-ray and MRI can indicate if the cause of a periosteal reaction is isolated or systemic, aggressive or non-aggressive, and the duration of the underlying cause. Children have more active bone growth and often have a more intense and aggressive appearance on imaging. If the cause is determined to be benign in origin, it is still important to get follow-up imaging to confirm that the reaction is resolving.

References:
1. Rana RS, Wu JS, Eisenberg RL. "Periosteal Reaction." American Journal of Roentgenology. 2009 Oct;193(4):W259-72

2. Yamada AF, Pelligrini JB, Cunha LM, Fernandes Ada R. "Osteitis after BCG vaccination." Jornal Brasileiro de Pneumologia. 2009 Mar;35(3):285-9

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