151. Vasculitis following SARS-CoV-2 vaccination
Creators: name: Haifeng Xu2
name: David RW Jayne2, 1
name: Stefanos1, Niki
name: Rachel Jones1, 2
Publisher: name: Zenodo
Year: 2022
Subjects: Vasculitis
ANCA
Abstracts
Giant Cell Arthritis
MPA
GPA
EGPA
Takayasu
IgA vasculitis

description: <strong>Background:</strong> SARS-CoV-2 vaccination can rarely trigger a heightened inflammatory response, notably vaccine-induced immune thrombotic thrombocytopenia (VITT). Case reports also suggest an association with SARS-CoV-2 vaccination and vasculitic reactions. <strong>Presentation of Case 1</strong>: A previously well 60 year old female developed small joint arthritis and myalgia following a first dose of Astra-Zeneca ChAdOx1-S/nCoV-19 adenoviral vector SARS-CoV-2 (AZ) vaccine in January 2021. Two weeks after the second AZ vaccine dose (April 2021), her arthritis worsened and she developed numbness and progressive weakness in her hands. Eight months after symptom onset she was hospitalised with an abdominal vesicular rash, diarrhoea and vomiting. <strong>Diagnostic Testing</strong>, <strong>Diagnosis</strong> and Management: CRP was elevated at 290 mg/L, liver function was abnormal (ALP 462 U/L, ALT 162 U/L) and she had a small pericardial effusion. Infection screen was normal apart from VZV DNA from her rash. Hepatitis screen and autoimmune serology were negative. CT excluded malignancy and found mild hepatic steatosis. She failed to respond to antibiotics and deteriorated, requiring non-invasive ventilation on intensive care. Further complications of radial artery and superficial venous thrombosis occurred in association with line insertions. Nerve conduction studies confirmed mononeuritis multiplex, sural nerve biopsy identified T cell infiltrate suggesting a vasculopathic process and bronchoscopy demonstrated diffuse alveolar haemorrhage. Dermatomal shingles was treated with aciclovir, following which intravenous methylprednisolone allowed rapid symptomatic improvement. Clinical findings along with exclusion of systemic infection and response to steroids led to a diagnosis of vaccine-induced ANCA negative small/medium vessel vasculitis. Given her disease severity she also received high dose oral prednisolone and cyclophosphamide which led to hospital discharge with CRP 39mg/L and improving liver function in October 2021. <strong>Presentation of Case</strong> 2: A 71 year old male presented with a lower limb purpuric rash, blisters on his fingers, arthritis and severe fatigue, eight days after a first dose of Pfizer-BioNTech BNT162b2 mRNA SARS-CoV-2 (Pfizer) vaccine (January 2021). He had previously treated bowel cancer in 2011. <strong>Diagnostic Testing</strong>, <strong>Diagnosis and Management</strong>: CRP was elevated at 400 mg/L; however, autoimmune serology and blood cultures were negative. A lung nodule was identified on CT scan. A clinical diagnosis of small vessel vasculitis was made and he received 3 months of tapering prednisolone 40 mg/day with symptomatic improvement. He received a second Pfizer vaccine dose in April 2021, following which his symptorecurred and he was hospitalised with breathlessness. CT demonstrated a pulmonary embolism, skin biopsy demonstrated fibrinoid necrosis, perivascular inflammation and thrombi (leucocytoclastic vasculitis). Oral prednisolone 40mg/day was restarted and tapered over 6 months. Follow-up imaging showed lung nodule resolution. In November 2021 he was symptom free (CRP &lt;4 mg/L) and he received a booster dose of the SARS-CoV-2 Moderna vaccine without complication. <strong>Discussion: </strong>These two cases highlight a temporal association between SARS-CoV-2 vaccination and systemic vasculitis with thromboses. Both patients responded to glucocorticoids, with additional cyclophosphamide use in one due to severe disease. Vaccine-induced vasculitis is well described, in particular after influenza vaccination; although population studies suggest the incidence is rare. SARS-CoV-2 vaccination is extremely common, and reports of associated vasculitic reactions are limited, suggesting that SARS CoV-2 associated vasculitis is also rare. <strong>Conclusions</strong>: Our report adds to the literature of a temporal association between Pfizer and AZ SARS-CoV-2 vaccination and de novo vasculitis. Awareness of this rare phenomenon is important for both diagnosis and treatments including glucocorticoids and anticoagulation. <strong>Disclosures: Dr Jones has received grants/consultancy fees from GlaxoSmithKline, Vifor Pharma, ChemoCentryx and Roche.</strong> David Jayne’s disclosures of commercial conflicts for companies with marketed products for 2021 are: Astra-Zeneca, Aurinia, BMS, Boehringer-Ingelheim, GSK, Janssen, Novartis, Roche/Genentech, Takeda &amp; Vifor. <strong>Figure 1.</strong> Skin biopsy from Case 2, with mid dermal perivascular inflammation, red cell extravasation and an organising vascular thrombus containing fibrin