A previously healthy 62-year-old Caucasian woman was referred to us with a 7–8 week history of constitutional symptoms following vaccination against coronavirus disease 2019 (COVID-19). The patient’s symptoms began 1–2… Click to show full abstract
A previously healthy 62-year-old Caucasian woman was referred to us with a 7–8 week history of constitutional symptoms following vaccination against coronavirus disease 2019 (COVID-19). The patient’s symptoms began 1–2 days after the first dose of the Pfizer-BioNTech COVID-19 vaccine. Initially, they consisted solely of fatigue. Three weeks later and following the second dose of the vaccine, she developed profuse night sweats. In the following weeks, she developed nausea and loss of appetite, and experienced a weight loss of 4 kg. She had no fever, headache, scalp tenderness, jaw claudication, visual disturbances, or polymyalgic symptoms. She had a family history of temporal arteritis (her father). After 7 weeks of illness, she consulted her general practitioner. The initial evaluation revealed a C-reactive protein (CRP) of 98 mg/L, normal leucocytes, and slightly increased immunoglobulin A and G. No focus of infection was found. Computed tomography (CT) of the thorax, abdomen, and pelvis showed no signs of malignancy. However, the scan revealed wall thickening throughout the aorta, common iliac arteries bilaterally, left subclavian artery, and proximal brachiocephalic artery, raising the suspicion of arteritis/aortitis. In addition, the CT scan showed signs of pericardial effusion as well as fatty liver. Echocardiography showed a minimal, haemodynamically irrelevant pericardial effusion of 0.8−1.3 cm and an otherwise normal heart. Electrocardiography was normal. On the suspicion of large vessel vasculitis, the patient was referred for rheumatological evaluation. A vascular ultrasound examination showed segmental hypoechoic wall thickening of the axillary arteries bilaterally consistent with vasculitis (Figure 1B). There were no signs of temporal artery involvement. Positron emission tomography–CT (PET-CT) showed diffuse, moderate-to-high [F]fluorodeoxyglucose (FDG) uptake in the vertebral, common carotid, maxillary, axillary, subclavian, internal mammary, and the proximal part of the common iliac arteries bilaterally and throughout the aorta (Figure 1A). Moderate FDG uptake in small lymph nodes in the left axilla was considered a sign of reactive lymphadenopathy to the vaccination (both doses were given in the left arm) (Figure 1A). There was no pathologically increased FDG uptake in the pericardium. Based on medical history, symptoms, clinical evaluation, urine analysis, laboratory screening, and blood cultures, infection (including tuberculosis, syphilis, and hepatitis B and C) and other rheumatological diseases (such as systemic lupus erythematosus and sarcoidosis) were excluded as a potential cause of secondary large vessel vasculitis. A diagnosis of large-vessel giant cell arteritis (GCA) was considered evident based on the patient’s age, clinical presentation (1), distribution of large vessel involvement, and exclusion of differential diagnoses. Treatment with 40 mg prednisolone was started, with good clinical response and CRP decreasing to 17 mg/L after 2 weeks. This supported the diagnosis of GCA. In addition, pericardial effusion was reevaluated, with no sign of progression. This case was reported to the Danish Medicines Agency as a possible side effect of the COVID-19 vaccine. To the best of our knowledge, this is the first case of GCA occurring immediately after COVID-19 vaccination to be reported. Many of the symptoms of GCA, such as fatigue, fever, headache, and muscle aches, are frequently reported as side effects of mRNA COVID-19 vaccines. Usually, the symptoms quickly recede and warrant no follow-up. In this case, the symptoms were persistent and worsened after the second dose. Some cases of GCA after vaccination, especially with the influenza vaccine, have been reported. Liozon et al reported 10 cases of post-influenza vaccine GCA and reviewed another nine cases from the literature (2). Their conclusion was that post-influenza vaccine onset of GCA or polymyalgia rheumatica (PMR) is not an exceptional occurrence and may represent a serious form of autoimmune/inflammatory syndrome induced by adjuvants (ASIA syndrome), especially in people with personal or familial risk of GCA/PMR. ASIA syndrome is thought to be triggered by the adjuvants 154 Scand J Rheumatol 2022;51:154–155
               
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