key: cord-0996191-rusge9t4
authors: Huang, Szu-Ting; Lee, Tai-Ju; Chen, Kai-Hsiang; Sun, Hsin-Yun; Chen, Wei-Ting; Hsieh, Song-Chou; Cheng, Aristine; Chen, Yee-Chun
title: Fatal myositis, rhabdomyolysis and compartment syndrome after ChAdOx1 nCoV-19 vaccination
date: 2022-04-25
journal: J Microbiol Immunol Infect
DOI: 10.1016/j.jmii.2022.04.003
sha: 8a2663216780c4b22b5d22f1e7a90f66694dbc56
doc_id: 996191
cord_uid: rusge9t4

nan

During the COVID-19 surge, vaccination is a key strategy to protect vulnerable populations. 1 As vaccine rollouts extend to less well-studied populations, novel descriptions of rare but important adverse events have emerged. Here, we present a case of fatal rhabdomyolysis and compartment syndrome after ChAdOx1-nCoV-19 vaccination.

A 44-year-old previously healthy man developed generalized myalgia after his second dose of the adenoviralbased vaccine. He presented to ER with progressive weakness and brown urine two weeks later. On admission, his blood tests showed markedly elevated creatinine, creatine kinase, and severe metabolic acidosis. His bilateral forearm and gastrocnemius muscles were tense, tender and his skin was mottled. Computed tomography revealed bilateral retroperitoneal fluid collection and swelling and edematous change of his psoas muscles (Fig. 1a) .

The patient was promptly intubated and initiated on continuous venovenous hemofiltration because of severe metabolic acidosis and anuria. Emergent fasciotomy was performed over his four limbs to relieve pressure from acute compartment syndrome. Muscle biopsy revealed neutrophilic myositis and small-vessel vasculitis with fibrin thrombi and C4d deposition (Fig. 1b & c) . The myositis panel was positive for anti-PM-Scl 100 autoantibodies. A heliotrope rash later developed over his eyelids. Dermatomyositis superimposed with rhabdomyolysis was impressed, and methylprednisolone (0.6 mg/kg/day) was given, followed by a pulsed dose of cyclophosphamide (3.6 mg/kg/day). In response to steroid therapy on day 7, his creatine kinase immediately peaked at 151058 U/L and declined rapidly thereafter (Fig. 1d) . However, the limb wounds during 8-hourly wet dressing change became infected. Initial blood cultures on admission and on day 3 did not yield any pathogen. On day 5 of admission, his open fasciotomy wounds became contaminated with carbapenem-resistant Acinetobacter baumanii (CRAB) and despite maximal support and appropriate antibiotics, the patient died of CRAB sepsis and multiorgan failure on day 17.

All published reports of post-COVID-19 vaccination rhabdomyolysis, comprising five men and three women, are listed in Table 1 . Two required dialysis, one died of multiorgan failure; both were elderly women who presented after mRNA COVID-19 vaccines. Four published cases of post-COVID-19 vaccination myositis have been reported from India following ChAdOx1-nCoV-19 vaccination. 2,3 One was a 46-year-old woman who was notable for a myositis profile positive for anti-Jo-1 and anti-Ro-52 autoantibodies who also developed rhabdomyolysis after the 2nd ChAdOx1-nCOV-19 dose. 3 All four patients with immune-mediated myositis received steroids AE mycophenolate mofetil and survived, despite one episode of pneumocystosis.

Our case is the first fatality to be reported among ethnic-Chinese and in a man without prior associations of advanced age, statin use, strenuous exercise, or myopathy. A proposed mechanism for post-vaccination rhabdomyolysis is an exaggerated immune response, in a predisposed individual, to previously circulating self-antigens or to released muscle-specific antigens following myonecrosis. Post-vaccination myositis, like COVID-19 associated myocarditis, may be increasingly observed because of the 

high antigenic similarity between the SARS-CoV-2 spike protein and human proteins. 4 In conclusion, we present a man in his prime who developed fulminant myositis, rhabdomyolysis, and renal failure after ChAdOx1-nCoV-19 vaccination. More awareness of this potential complication may ameliorate outcomes.

Rapid response of a medical center upon the surge of COVID-19 epidemic in Taiwan

Inflammatory myositis after ChAdOx1 vaccination

COVID-19 vaccination-associated anti-Jo-1 syndrome

A possible role for anti-idiotype Antibodies in SARS-CoV-2 infection and vaccination