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CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 14-16

Novel diagnosis of systemic lupus erythematosus after first dose of COVID-19 vaccination


Division of Rheumatology, Sinai Health System/University Health Network, University of Toronto, Ontario, Canada

Date of Submission12-Dec-2021
Date of Decision01-Mar-2022
Date of Acceptance02-Mar-2022
Date of Web Publication25-May-2022

Correspondence Address:
Dr. Jorge Sanchez-Guerrero
60 Murray St. 2-005. Toronto, ON, M5T 3L9
Canada
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ara.ara_10_21

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  Abstract 


In the literature, there are two case reports of new diagnoses of systemic lupus erythematosus including a patient with early-onset of class V nephritis; both cases had received the AstraZeneca Vaccine. There are also several cases-reports of autoimmune disease flares after receiving the first or the second dose of the different COVID-19 vaccinations. The severity of the disease flares, the number of doses after which the disease flared, and the approach to control the flare manifestations vary across the reports. The majority of the case reports focus on disease activation rather than a newly diagnosed autoimmune disease after receiving the COVID-19 vaccines. Here, we report a young female with new-onset systemic lupus erythematosus manifesting with arthritis, cutaneous manifestations, and fever 5 days after the first dose of (ChAdOx1 nCoV-19) vaccine.

Keywords: Arthritis, autoimmune diseases, connective tissue disease, COVID-19 vaccination, systemic lupus erythematosus


How to cite this article:
Alshahrani KS, Sanchez-Guerrero J. Novel diagnosis of systemic lupus erythematosus after first dose of COVID-19 vaccination. Ann Rheumatol Autoimmun 2022;2:14-6

How to cite this URL:
Alshahrani KS, Sanchez-Guerrero J. Novel diagnosis of systemic lupus erythematosus after first dose of COVID-19 vaccination. Ann Rheumatol Autoimmun [serial online] 2022 [cited 2022 Dec 10];2:14-6. Available from: http://www.ara.ssr.com/text.asp?2022/2/1/14/345950




  Introduction Top


The latest advances in the COVID-19 vaccination field are a major step toward proper control of the surge of the pandemic. Different types of vaccinations with varied platforms are available. Overall, approved vaccines are safe in rheumatic diseases including systemic lupus erythematosus.[1] Here, we report a woman with new-onset systemic lupus erythematosus 5 days after vaccination with the first dose of the COVID-19 vaccine.


  Case Report Top


A 44-year-old woman with no previous history of chronic diseases, no medications use, and no family history of autoimmune diseases. She received the first dose of AZD1222 (ChAdOx1 nCoV-19) vaccine (AstraZeneca) in April 2021 in fulfillment of the international and local authorities' recommendations. Five days after receiving the vaccine, she started noticing bilateral shoulder pain with morning stiffness and restriction of movement on daily basis lasting more than 45 min. Furthermore, she developed pain and swelling with morning stiffness involving the hands' joints, wrists, knees, and ankles. Along with the articular symptoms, she noticed significant scalp hair thinning and fall and weight loss of 15 pounds. Physical examination revealed normal vital signs. Two bald spots were noticed on the scalp. Active synovitis with tenderness, swelling, and restriction of movement in metacarpophalangeal and proximal interphalangeal joints bilateral, wrists, and knees. The laboratory tests were significant for anemia, hypoalbuminemia, high erythrocyte sedimentation rate and C-reactive protein (CRP), positive ANA, anti-dsDNA, anti-RNP, Smith/RNP antibodies, and low C3 levels [Table 1]. The urine analysis test, liver tests, and renal function tests were normal.
Table 1: Laboratory test results at first clinical assessment

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She was treated with prednisone 20 mg daily with clinical improvement but after tapering the dose of prednisone, the symptoms recurred. When we assessed her the first-time in late September 2021, the dose of prednisone was increased to 20 mg daily, and hydroxychloroquine 200 mg daily, methotrexate 12.5 mg PO weekly, and folic acid were started. At the subsequent assessment in early November 2021, she referred to significant improvement of the symptoms and specifically 80%–90% improvement in joint symptoms. The hemoglobin improved to 106, serum albumin 41, CRP 0.6, anti-DNA 14, C3 0.67, and C4 0.16.


  Discussion Top


In the literature, two recent reports of new-onset SLE after COVID-19 vaccine are available. The first case started with arthralgia 2 weeks after the first dose of ChAdOx1-S, and fever, cutaneous manifestations, lymphadenopathy, and hepatomegaly after the second dose.[2] The second case developed nephrotic syndrome due to membranous nephropathy 1 week after the first dose of the vaccine ChAdOx1-S.[3]

A cause-effect relationship between the vaccine and SLE onset cannot be stated. In our case and the one with class V nephritis, the clinical symptoms started within a week of the first dose of the vaccine. In addition to the clinical manifestations, the lupus serology showed positivity for several autoantibodies including ANA, anti-dsDNA, Sm/RNP, RNP, SSA, and chromatin. It is known that the development of these antibodies precedes the onset of SLE for a long time.[4] Given that millions of people already received the vaccine against COVID, the two published cases of new-onset SLE plus our case fall within the expected incidence rate.

Recent reports of newly diagnosed rheumatic diseases shortly after receiving the COVID-19 vaccinations are available including Adult-onset Still's disease,[5] polymyalgia rheumatica disease,[6] and remitting seronegative symmetrical synovitis with pitting edema (RS3PE).[7]

The known different platforms for the newly developed COVID-19 vaccines were previously expected to have almost the same reactions by the human body; however, although rare, serious adverse events reports are being published and recognized. Recently published phase 3 clinical trial of the safety and efficacy of (ChAdOx1 nCoV-19) vaccine with randomization of 32,451 participants reported that the general pain, headache, and the injection site pain to be the most common adverse events within 28 days after the vaccination dose, with way less comparable reported serious adverse events in both arms of the trial.[8] While the major initial trials for developing COVID-19 vaccinations excluded the patients with autoimmune diseases, the exact mechanism of how the vaccinations might trigger the reactivation of the autoimmune disease is still not fully clear. Foreign nucleic acid can increase interferon production by cells through the activation of Toll-like receptors (TLR7 and TLR8).[9] An evaluation of the immunostimulation in both humans and mice after receiving the influenza-A vaccine (m-RNA based) showed an upregulation of the innate and adaptive immune system through the activation and maturation of the immune cells and an increase of the production of the cytokines and chemokines.[10]


  Conclusion Top


As our knowledge regarding the possible reactogenicity to the COVID-19 vaccinations is growing, health-care professionals should be aware and vigilant to the possible events after COVID-19 vaccinations for better recognition and anticipation of some rare events.

Consent for publication

Informed consent was obtained from the patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Felten R, Kawka L, Dubois M, Ugarte-Gil MF, Fuentes-Silva Y, Piga M, et al. Tolerance of COVID-19 vaccination in patients with systemic lupus erythematosus: The international VACOLUP study. Lancet Rheumatol 2021;3:e613-5.  Back to cited text no. 1
    
2.
Patil S, Patil A. Systemic lupus erythematosus after COVID-19 vaccination: A case report. J Cosmet Dermatol 2021;20:3103-4.  Back to cited text no. 2
    
3.
Zavala-Miranda MF, González-Ibarra SG, Pérez-Arias AA, Uribe-Uribe NO, Mejia-Vilet JM. New-onset systemic lupus erythematosus opening as class V lupus nephritis after COVID-19 vaccination. Kidney Int 2021;100:1340-1.  Back to cited text no. 3
    
4.
Arbuckle MR, McLain MT, Rubertone MV, Scofield RH, Dennis GJ, James JA. Development of auto-antibodies before the clinical onset of systemic lupus erythematosus. Rev Med Interne 2004;25:175-6.  Back to cited text no. 4
    
5.
Magliulo D, Narayan S, Ue F, Boulougoura A, Badlissi F. Adult-onset Still's disease after mRNA COVID-19 vaccine. Lancet Rheumatol 2021;3:e680-2.  Back to cited text no. 5
    
6.
Manzo C, Natale M, Castagna A. Polymyalgia rheumatica as uncommon adverse event following immunization with COVID-19 vaccine: A case report and review of literature. Aging Med (Milton) 2021;4:234-8. [doi: 10.1002/agm2.12171].  Back to cited text no. 6
    
7.
Parperis K, Constantinou M. Remitting seronegative symmetrical synovitis with pitting oedema following BNT162b2 mRNA COVID-19 vaccination. BMJ Case Rep 2021;14:e244479.  Back to cited text no. 7
    
8.
Falsey AR, Sobieszczyk ME, Hirsch I, Sproule S, Robb ML, Corey L, et al. Phase 3 safety and efficacy of AZD1222 (ChAdOx1 nCoV-19) COVID-19 vaccine. N Engl J Med 2021;385:2348-60.  Back to cited text no. 8
    
9.
Isaacs A, Cox RA, Rotem Z. Foreign nucleic acids as the stimulus to make interferon. Lancet 1963;2:113-6.  Back to cited text no. 9
    
10.
Edwards DK, Jasny E, Yoon H, Horscroft N, Schanen B, Geter T, et al. Adjuvant effects of a sequence-engineered mRNA vaccine: Translational profiling demonstrates similar human and murine innate response. J Transl Med 2017;15:1.  Back to cited text no. 10
    



 
 
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