key: cord-1003938-fosftcfy
authors: Al-Allaf, Abdul-Wahab; Razok, Almurtada; Al-Allaf, Yousr; Aker, Loai
title: Post-COVID-19 vaccine medium-vessel vasculitis and acute anterior uveitis, causation vs temporal relation; case report and literature review
date: 2022-02-24
journal: Ann Med Surg (Lond)
DOI: 10.1016/j.amsu.2022.103407
sha: 517fed7f82ffa062d4d3dbe6bbf728a56624f625
doc_id: 1003938
cord_uid: fosftcfy

INTRODUCTION: and importance: Multiple immunologic phenomena were reported following the administration of COVID-19 vaccines. However, the important point is that their possible association with medium-vessel vasculitis involving the celiac trunk and its branches with acute anterior uveitis in the same patient has not been reported before. CASE PRESENTATION: In this manuscript, we are reporting a case of a middle-aged gentleman who developed vasculitis involving the celiac trunk and its branches, and acute anterior uveitis one week and three weeks after the second dose of Pfizer BioNTech COVID-19 vaccine, respectively. The patient showed significant clinical and radiographic improvement after receiving corticosteroids and azathioprine. CLINICAL DISCUSSION: Previously reported cases of vasculitis following COVID-19 vaccines included both renal-limited and more generalized vasculitis with some being positive and others negative for ANCA (anti-neutrophil cytoplasmic antibodies). Nevertheless, it is worth mentioning that most cases responded to immunosuppressive treatment. Post-COVID-19 vaccine uveitis was reported in patients with different age spans including both anterior and posterior uveitis, with remission being achieved after the use of corticosteroids. CONCLUSIONS: Multiple cases of vasculitis and acute anterior uveitis were reported following COVID-19 vaccines; however, it is important to mention that more research is needed to establish an association between the COVID-19 vaccine and both vasculitis and acute anterior uveitis. In our opinion, the benefits of the COIVID-19 vaccine largely outweigh the expected risks.

1 Abstract:

Multiple immunologic phenomena were reported following the administration of vaccines. However, the important point is that their possible association with medium-vessel vasculitis involving the celiac trunk and its branches with acute anterior uveitis in the same patient has not been reported before.

In this manuscript, we are reporting a case of a middle-aged gentleman who developed vasculitis involving the celiac trunk and its branches, and acute anterior uveitis one week and three weeks after the second dose of Pfizer BioNTech COVID-19 vaccine, respectively. The patient showed significant clinical and radiographic improvement after receiving corticosteroids and azathioprine.

Previously reported cases of vasculitis following COVID-19 vaccines included both renallimited and more generalized vasculitis with some being positive and others negative for ANCA (anti-neutrophil cytoplasmic antibodies). Nevertheless, it is worth mentioning that most cases responded to immunosuppressive treatment. Post-COVID-19 vaccine uveitis was reported in patients with different age spans including both anterior and posterior uveitis, with remission being achieved after the use of corticosteroids.

Multiple cases of vasculitis and acute anterior uveitis were reported following COVID-19 vaccines; however, it is important to mention that more research is needed to establish an association between the COVID-19 vaccine and both vasculitis and acute anterior uveitis. In our opinion, the benefits of the COIVID-19 vaccine largely outweigh the expected risks.

COVID-19 vaccine; Vasculitis; Celiac trunk; Anterior uveitis; Immunosuppressive medications.

Since the emergence of the COVID-19 virus in late 2019, the world has been preoccupied with its negative impacts on public health worldwide. Due to the catastrophic effects of the COVID-J o u r n a l P r e -p r o o f on an emergency basis, which include Pfizer BioNTech, Moderna and Johnson & Johnson [2] .

After the widespread use of COVID-19 vaccines, a variety of local and systemic reactions were observed. The local side effects included pain, erythema and swelling [3] , but more worrying were the various systemic reactions including a variety of immune-mediated conditions such as Guillain-Barre syndrome, Vaccine-associated Immune Thrombosis and Thrombocytopenia (VITT) syndrome and myocarditis [4] . Many cases of small-vasculitis following the COVID-19 vaccine were reported [5, 6] . We report a case of isolated medium-vessel vasculitis involving the celiac trunk and its branches one week after the second dose of the Pfizer BioNTech COVID-19 vaccine. To the best of our knowledge, this is the first case report of post-COVID-19 vaccine celiac trunk vasculitis. We would like our physician colleagues to be vigilant about such an association. However, at the same time, we would like to emphasize that the benefits of the COVID-19 vaccine outweigh these possible associated adverse reactions and that such temporal relation is not approved for causation. More research is needed to establish a causal relationship between these reactions and COVID-19 vaccines.

A 46-year-old gentleman who is overweight, smoker, with no history of alcohol consumption or any significant family history, with the background of well-controlled essential hypertension on amlodipine 5 mg daily. He presented to the emergency department (ED) on 16/03/2021 with a chief complaint of epigastric and left upper quadrant abdominal pain for six days duration. The pain was non-radiating, severe in intensity, rated as 7/10 as per the normalized scale ratio (NRS), stabbing in nature and did not respond adequately to oral analgesics such as paracetamol and ibuprofen. There was no nausea, vomiting, alteration in bowel habits or urinary complaints. He had received the second dose of the Pfizer BioNTech COVID-19 vaccine a week before that, on 09/03/2021, after which he experienced fever and rigors for the first day. Both doses of the vaccine were administered in the left deltoid muscle area. He worked as a driver and had not recently travelled. The history was negative for photosensitivity, oral ulcers, joint pain, sicca symptoms, lymphadenopathy, weight loss and night sweats. In the ED, he had normal vital signs including oral and axillary temperature. His labs were pertinent for mildly elevated C-reactive protein of 20.3 mg/dl (reference range 0-5 mg/dl) but were otherwise normal including negative Furthermore, there was a resolution of the previously noted narrowing of the celiac trunk and its branches. Accordingly, after that, his steroid was completely stopped on 28.09.2021, around 6 months after his initial presentation and has been advised to continue with the Azathioprine 150 mg daily. He has been reviewed 3 months later and he continued to be in remission. The patient confirmed daily adherence to the prescribed treatment and did not report any therapy-related adverse events during the follow-up period.

New-onset vasculitis following COVID-19 vaccination was reported in multiple patients. Of note, two case reports described renal-limited, ANCA-positive vasculitis in patients who were found to have acute kidney injury. The first case was about a 78-year-old lady who presented with nausea and vomiting 16 days after receiving the Pfizer-BioNTech COVID-19 vaccine and was found to have antibodies against myeloperoxidase (MPO) and pauci-immune necrotizing glomerulonephritis. Renal function parameters improved after receiving corticosteroids and rituximab [8] . The second case reported, was a 52-year-old gentleman who presented with headache and weakness two weeks after receiving the second dose of the Moderna mRNA vaccine and was also found to have pauci-immune necrotizing glomerulonephritis but with antibodies against proteinase-3 (PR3). Unfortunately, his renal function deteriorated despite administering rituximab and cyclophosphamide, which necessitated the initiation of hemodialysis [9] .

An additional case report described a 77-year-old gentleman who presented with fever and night sweats four weeks following the first dose of the AstraZeneca COVID-19 vaccine and was found to have acute non-necrotizing granulomatous nephritis which subsided within four weeks of receiving methylprednisolone. Interestingly, the patient had negative anti-neutrophil cytoplasmic antibodies, however, there was evidence of medium-vessel involvement on positron emission tomography scan (PET) [10] .

In relation to post-COVID-19 vaccine uveitis, multiple cases were reported as well, and both anterior and posterior uveitis were observed. In one report, a 15-year-old girl with a background of antinuclear antibodies-positive juvenile idiopathic arthritis developed bilateral anterior uveitis five days after receiving the second dose of the Sinopharm COVID-19 vaccine. Her condition improved after receiving topical steroids [11] . In addition, a case of bilateral posterior uveitis was reported in a 50-year-old lady with no medical background who developed bilateral blurred vision also five days after receiving the inactivated COVID-19 vaccine. The patient responded to therapy with topical and systemic steroids [12] .

The unique and novel aspects of the case we are reporting include the post-COVID-19 vaccine medium-vessel vasculitis involving the celiac trunk and its branches and the development of unilateral acute anterior uveitis, in addition to the co-existence of both conditions in the same patient, which to the best of our knowledge, has not been reported before.

Considering the inability to confirm the association between vasculitis and uveitis on one hand and the COVID-19 vaccine on the other on the molecular level, despite the temporal association, we cannot presume for sure that the vaccine is the causative agent for his vasculitis and the uveitis.

We would like to express our opinion that the benefits of the COVID-19 vaccine outweigh the possible associated risks on both the individual and community levels and that more research is needed to confirm or rule out the possible association between the COVID-19 vaccine and the adverse events reported in this and other manuscripts.

Possible complications of COVID-19 vaccines have become of special interest to both healthcare workers and the public. We report this case to raise awareness about abdominal vasculitis and acute anterior uveitis as possible complications of COVID-19 vaccination. We hope that our manuscript will serve as a bridge for future studies that will further investigate these topics and will alarm healthcare workers to consider vasculitis as a cause of otherwise unexplained abdominal pain following the COVID-19 vaccine.

Highlights:

• This is the first case report for medium vessel vasculitis after a COVID-19 vaccine, which we think it is of special interest to the public .

• We are not sure if this has a chance or casual association and we think more studies are needed to assert an association with COVID-19 vaccine.

• We think that this is a transient condition and it could be managed in the same line for managing vasculitis.

• This should not deter us from using the COVID vaccine, which is essential to alter the course of the COVID epidemic.

This work was reported in line with the SCARE guidelines [7] .

Availability of data and materials:

J o u r n a l P r e -p r o o f

Orgill, for the SCARE Group. The SCARE 2018 statement: Updating consensus Surgical CAse REport (SCARE) guidelines

Looking beyond COVID-19 vaccine phase 3 trials

Adverse Events Reported From COVID-19 Vaccine Trials: A Systematic Review

Post-COVID-19 vaccine Guillain-Barré syndrome; first reported case from Qatar

New-onset leukocytoclastic vasculitis after COVID-19 vaccine

First description of immune complex vasculitis after COVID-19 vaccination with BNT162b2: a case report

The SCARE 2020 Guideline: Updating Consensus Surgical CAse REport (SCARE) Guidelines

ANCA-Associated Vasculitis Following Pfizer-BioNTech COVID-19 Vaccine

ANCA glomerulonephritis after the Moderna COVID-19 vaccination

Granulomatous vasculitis after the AstraZeneca anti-SARS-CoV-2 vaccine

Acute Uveitis following COVID-19 Vaccination

Bilateral uveitis after inoculation with COVID-19 vaccine: A case report

J o u r n a l P r e -p r o o f Highlights:• This is the first case report for medium vessel vasculitis after a COVID-19 vaccine, which we think it is of special interest to the public .• We are not sure if this has a chance or casual association and we think more studies are needed to assert an association with COVID-19 vaccine.• We think that this is a transient condition and it could be managed in the same line for managing vasculitis.• This should not deter us from using the COVID vaccine, which is essential to alter the course of the COVID epidemic.J o u r n a l P r e -p r o o f

The following information is required for submission. Please note that failure to respond to these questions/statements will mean your submission will be returned. If you have nothing to declare in any of these categories then this should be stated.

All authors must disclose any financial and personal relationships with other people or organisations that could inappropriately influence (bias) their work. Examples of potential conflicts of interest include employment, consultancies, stock ownership, honoraria, paid expert testimony, patent applications/registrations, and grants or other funding.None to be declared.

All sources of funding should be declared as an acknowledgement at the end of the text. Authors should declare the role of study sponsors, if any, in the collection, analysis and interpretation of data; in the writing of the manuscript; and in the decision to submit the manuscript for publication. If the study sponsors had no such involvement, the authors should so state.This article did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Open access funding will be provided by Qatar National Library (QNL).

Research studies involving patients require ethical approval. Please state whether approval has been given, name the relevant ethics committee and the state the reference number for their judgement.Written informed consent was obtained from the patient for publication of this case report and the accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.J o u r n a l P r e -p r o o f Consent Studies on patients or volunteers require ethics committee approval and fully informed written consent which should be documented in the paper.Authors must obtain written and signed consent to publish a case report from the patient (or, where applicable, the patient's guardian or next of kin) prior to submission. We ask Authors to confirm as part of the submission process that such consent has been obtained, and the manuscript must include a statement to this effect in a consent section at the end of the manuscript, as follows: "Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request".Patients have a right to privacy. Patients' and volunteers' names, initials, or hospital numbers should not be used. Images of patients or volunteers should not be used unless the information is essential for scientific purposes and explicit permission has been given as part of the consent. If such consent is made subject to any conditions, the Editor in Chief must be made aware of all such conditions. Even where consent has been given, identifying details should be omitted if they are not essential. If identifying characteristics are altered to protect anonymity, such as in genetic pedigrees, authors should provide assurance that alterations do not distort scientific meaning and editors should so note.Written informed consent was obtained from the patient for publication of this case report and the accompanying image. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Please specify the contribution of each author to the paper, e.g. study concept or design, data collection, data analysis or interpretation, writing the paper, others, who have contributed in other ways should be listed as contributors.AWA provided the case who is under his care and provided advisory and scientific support, he reviewed and proved the final version. AR performed literature review and wrote the first draft of the manuscript. YA reviewed and edited the manuscript from scientific and English language point of view to its final version. LA provided informative radiological images for the case and their captions.

In accordance with the Declaration of Helsinki 2013, all research involving human participants has to be registered in a publicly accessible database. Please enter the name of the registry and the unique identifying number (UIN) of your study.You can register any type of research at http://www.researchregistry.com to obtain your UIN if you have not already registered. This is mandatory for human studies only. Trials and certain observational research can also be registered elsewhere such as: ClinicalTrials.gov or ISRCTN or numerous other registries.Not applicable, the manuscript is a case report.

The Guarantor is the one or more people who accept full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish Abdul-Wahab Al-Allaf J o u r n a l P r e -p r o o f