She had no significant past medical history and no known allergies. She had not previously been vaccinated against JE but was felt to be at significant risk. She received 3 × 1 mL subcutaneous doses of JE-MB (BIKEN) vaccine on days 0, 7, and 28, accompanied by 3 × 1 mL intradermal doses of human diploid cell rabies vaccine. Following the third dose, she developed an urticarial rash all over her body and experienced mild respiratory disturbance. She was treated with intramuscular antihistamine, the symptoms resolved, and she did not require

admission to hospital. Three years later MB was returning to rural India as a tourist. Serology revealed no IgG antibodies to JE and after discussion of the likely risks with a vaccine that was unlikely to constitute a similar risk she elected to be revaccinated Lumacaftor with JE-VC (IXIARO) vaccine. She suffered no immediate reaction and was discharged home after 2 hours observation in our outpatient Metformin datasheet department. Three days later, she noted an itchy, papular rash at her hairline and on her inner wrists, which, the next day, spread to her scalp and upper body. This remained pruritic and appeared urticarial. She took 10 mg of cetirizine, 8 mg of chlorphenamine, and after 5 days from onset her symptoms had resolved. There was no associated respiratory distress. Three months later, serology revealed IgG to JE. Adverse events such as rash and urticaria

are recognized complications of JE-MB vaccination, and have been noted to occur as many as 17 days following vaccination and in as many as 5% of vacinees.[4] Similarly, adverse reactions to JE-VC may occur up to 8 days following vaccination.[8] In the safety studies for JE-VC, one case of generalized urticaria was noted 8 days following vaccination, and treated with cetirizine hydrochloride with symptom resolution after 3 days,[9] a similar event to that occurring in our patient. Adverse

reactions following a prior dose of JE-MB manifesting as generalized urticaria and angioedema are considered contraindications to further vaccination.[4] Those with previous urticarial reactions following hymenoptera envenomation, drugs, or other provocations were at greater risk of reaction to JE-MB.[4] The JE-VC vaccine does not contain the stabilizers and excipients of the JE-MB vaccine and we considered it a second safe option for boosting immunity in this patient. JE-VC contains protamine sulphate, associated with hypersensitivity reactions, but this is not seen in JE-MB.[2] Compared to a vaccine excipient placebo, JE-VC was seen to have a comparable proportion and severity of adverse reactions, and compared to JE-MB, JE-VC recipients had significantly fewer local reactions.[7-9] Furthermore, no hypersensitivity reactions featuring angioedema have been reported in JE-VC recipients. When compared to JE-MB, JE-VC had a reported hypersensitivity rate of 3.6/100,000 doses compared to 8.4.