Age: 53.0
Sex: M
Vaccine: COVID19
Symptoms: Angiogram, Angiotensin converting enzyme, Antineutrophil cytoplasmic antibody, Biopsy, Blood lactate dehydrogenase
Clinical narrative: Lofgren syndrome, suspected to have developed with relationship to his Covid-19 booster; This literature-non-study case was reported in a literature article and describes the occurrence of LOEFGREN SYNDROME (Lofgren syndrome, suspected to have developed with relationship to his Covid-19 booster) in a 53-year-old male patient who received SPIKEVAX NOS (SPIKEVAX NOS) for COVID-19 prophylaxis.   Concurrent medical conditions included Smoker (10 pack-year active smoking history).    On an unknown date, the patient received dose of SPIKEVAX NOS (SPIKEVAX NOS) (unknown route) 1 dosage form. On an unknown date,  after starting SPIKEVAX NOS (SPIKEVAX NOS), the patient experienced LOEFGREN SYNDROME (Lofgren syndrome, suspected to have developed with relationship to his Covid-19 booster) (seriousness criterion medically significant). At the time of the report, LOEFGREN SYNDROME (Lofgren syndrome, suspected to have developed with relationship to his Covid-19 booster) was resolving.      DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On an unknown date, Angiogram: Chest CT angiography showed diffuse peri-lymph vascular micronodular infiltrates involving fissures with hilar lymphadenopathy. On an unknown date, Angiotensin converting enzyme: was elevated at 58. On an unknown date, Antineutrophil cytoplasmic antibody: 1:320. On an unknown date, Biopsy: Macular rash was biopsied. Pathology revealed subcuticular expansion of the interlobular septa of the fat by mucin/edema and collagen accompanied by a mixed cellular infiltrate comprising histiocytes as well as neutrophils and lymphocytes. Histiocytes surrounded and permeated vessels defining an incipient granulomatous vasculopathy. A diagnosis was made of erythema nodosum. Subsequent staining identified Sars-Covid-19 spike glycoprotein in the deep subcutaneous microvessels exhibiting endothelial localization. On an unknown date, Blood lactate dehydrogenase: 243. On an unknown date, C-reactive protein: 14. On an unknown date, Echocardiogram: normal. On an unknown date, Electrocardiogram: normal. On an unknown date, Physical examination: reveals maxillary sinus tenderness, a firm macular lower extremity extensor rash with plaques and swollen, tender ankle joints. On an unknown date, Protein urine: Proteinuria was present. On an unknown date, Red blood cell sedimentation rate: 110. On an unknown date, Rheumatological examination: Negative. On an unknown date, Transaminases: were mildly elevated in a hepatocellular pattern.     For SPIKEVAX NOS (SPIKEVAX NOS) (Unknown), the reporter considered LOEFGREN SYNDROME (Lofgren syndrome, suspected to have developed with relationship to his Covid-19 booster) to be related.    Concomitant and medications were not reported.  Patient with no medical history presents with 2.5 months of nasal pressure, lower-extremity rash and bilateral ankle pain with joint swelling, starting 3 days after a Moderna TX SARS Covid-19 booster vaccine. Patient endorses night-sweats, fatigue and an acute 15-pound weight-loss without other symptoms. Patient takes no medications and has no allergies. Patient had a recent water pipe leak, with no other occupational or environmental exposures.  An exhaustive infectious and rheumatologic workup was otherwise negative. The patient's combined clinical, imaging, and pathological findings were consistent with Lofgren syndrome, suspected to have developed with relationship to his Covid-19 booster.  In this case, there was a direct temporal relationship between syndrome development and vaccination. The patient rapidly improved on an unspecified glucocorticoid.  Author stated this case demonstrates the pathognomonic constellation of bilateral hilar lymphadenopathy, erythema nodosum, bilateral ankle arthritis and fever. Typically, Lofgren is triggered by organisms with superantigen properties, such as Yersinia, Streptococcus and Mycobacterium. A true Gell and Coombs type IV immune reaction, reflective of a robust adaptive cellular immune response, is the probable etiologic basis. Like the other implicated microbial pathogens unique to Lofgren's syndrome, spike glycoprotein has superantigen properties and therefore stimulates a significant component of the T-cell repertoire to produce this overzealous systemic type IV hypersensitivity reaction.  Company Comment: This is a literature non-study case concerning a 53 year-old, male patient with no relevant medical history, who experienced the serious (due to medically significant) unexpected, event of Loefgren syndrome, which occurred 3 days after the booster dose of SPIKEVAX COVID-19 VACCINE NOS. Patient reported nasal pressure, lower-extremity rash and bilateral ankle pain with joint swelling, starting 3 days after vaccination, accompanied by night-sweats, fatigue and an acute 15 pound weight-loss without other symptoms. Physical examination revealed maxillary sinus tenderness, a firm macular lower extremity extensor rash with plaques and swollen, tender ankle joints. Lab tests showed elevations in erythrocyte sedimentation rate (110), c-reactive protein (14) and lactate dehydrogenase (243). His angiotensin-converting enzyme level was elevated at 58, and his anti-neutrophil antibody was 1:320 (no units nor reference range provided for any test). Transaminases were mildly elevated in a hepatocellular pattern and proteinuria was present. An exhaustive infectious and rheumatologic workup was negative. An EKG and trans-thoracic echocardiogram were normal. Chest CT angiography showed diffuse peri-lymphovascular micronodular infiltrates involving fissures with hilar lymphadenopathy. The macular rash was biopsied. Pathology revealed subcuticular expansion of the interlobular septa of the fat by mucin edema and collagen accompanied by a mixed cellular infiltrate comprising histiocytes as well as neutrophils and lymphocytes. Histiocytes surrounded and permeated vessels defining an incipient granulomatous vasculopathy. A diagnosis was made of erythema nodosum. Subsequent staining identified Sars-Covid-19 spike glycoprotein in the deep subcutaneous microvessels exhibiting endothelial localization. The patients combined clinical, imaging, and pathological findings (pathognomonic constellation of bilateral hilar lymphadenopathy, erythema nodosum, bilateral ankle arthritis and fever) were consistent with Lofgren syndrome, suspected to have developed with relationship to his Covid-19 booster according to the authors. The patient rapidly improved on glucocorticoids. The benefit-risk relationship of SPIKEVAX COVID-19 VACCINE NOS is not affected by this report.