Immunization gives protection against infectious diseases, but immunization itself is associated with morbidity because of side effects and adverse events.¹ Children scheduled for urgent surgery requiring general anesthesia may have been vaccinated recently. The fever or malaise in response to vaccination is of concern in a child who is scheduled for urgent surgery, and needs to be differentiated from that arising from any infective etiology.

A 3.5-month-old 4-kg male child, with a diagnosed case of retinoblastoma of the left eye was scheduled for enucleation. On preanesthetic evaluation, the child was found to have been febrile (37.7ºC) for 1 day. Fever was continuous and not associated with chills or rigor. There was no history suggestive of any systemic illness, including respiratory tract infection. The parents gave a history of DPT (diphtheria, tetanus toxoid and acellular pertussis) and OPV (oral polio vaccine) vaccinations 1 day previously. On examination, the heart rate was 136 beats per minute and the respiratory rate was 24 breaths per minute. Chest auscultation revealed equal bilateral air entry without any added sounds. The child was advised to take paracetamol syrup. The next day, prior to anesthesia, his temperature was 37ºC. In the operation room, routine monitors (electrocardiogram, pulse oximeter, noninvasive blood pressure) were attached and general anesthesia was administered as per the standard protocol. Peribulbar block using 0.25% bupivacaine was done and a paracetamol rectal suppository was administered for perioperative analgesia; the operation was uneventful. Paracetamol syrup was continued for the next 2 days. The child had an uneventful recovery.

This child received immunization with DPT and OPV scheduled at 14 weeks of age, a day prior to surgery. The stress of anesthesia and surgery may lead to immunoparesis by suppression of the immune system, and an inadequate antibody response to vaccine antigens which may result in vaccination failure. Such immunosuppression is of short duration, and there is no evidence that any of the routine childhood vaccines have failed as a result of anesthesia or surgery. On the contrary, the anesthesia techniques (regional anesthesia) which inhibit the stress responses have a beneficial effect on the immune function. Thus, we administered peribulbar block in our patient to provide reinforced analgesia and decrease the surgical stress, though in the literature using such a block in a recently vaccinated child has not been described. Bal anced anesthesia transiently enhances phagocytosis and microbicidal oxidative functions in leukocytes and monocytes.² Therefore, physiological homeostasis and adequate analgesia in the perioperative period must be provided if the surgery cannot be delayed as happened in our case. After vaccination, the most common side effects seen are fever, malaise, headache, rash and myalgia, which may last from 1 day to 3 weeks. Delaying oncological surgery, such as that for retinoblastoma, may affect the treatment outcome. If the malaise associated with immunization occurs concurrently with the trauma of surgery and the effects of the associated anesthesia, then recovery may be prolonged or complicated by additional physiological alterations, which could be avoided if the child was allowed to recover from the effects of the immunization prior to the surgery.¹ In addition, some of these features may be confused with those caused by the infective pathology. It is imperative to elicit the history of vaccination along with the clinical examination and relevant investigations to rule out any infective pathology. It has been recommended to immunize children who are scheduled for elective surgery, but the possibility of delaying surgery for 2 days (with inactivated vaccines) or 21 days (with live vaccines) after vaccination should be contemplated to prevent confusion between possible vaccine-related adverse events and postoperative complications.² However, there are no recommendations or guidelines regarding vaccination status and urgent surgery.

We conclude that a child with fever or malaise after vaccination should be examined closely to rule out any infective pathology, and balanced anesthesia with multimodal analgesia including regional block should be provided for urgent surgery such as enucleation of the eye for retinoblastoma.