[SARS-CoV-2 infection triggering a giant cell arteritis]

Isolated popliteal artery lesion due to giant cell vasculitis post COVID-19 mRNA vaccine and COVID-19 asymptomatic infection

OBJECTIVE

Giant cell arteritis (GCA) is a rare granulomatous vasculitis, affecting medium and large vessels, usually in old patients. The incidence of GCA has been higher during current COVID-19 pandemia and COVID-19 is recognized for its immune dysregulation. Lower limbs involvement is uncommon but can be limb threatening, resulting in limb loss.

METHOD

A 43-year-old man presented with a sudden pain in his right calf and foot associated with pallor and hypothermia, and there was objective evidence of ischemia. Symptoms began few days after he received the first dose of a COVID-19 mRNA vaccine and COVID-19 asymptomatic infection 20 days after vaccination. He had no history of any signs of claudication pre-COVID or limb trauma and was very fit.Enhanced computed tomography and magnetic resonance imaging (MRI)suggest diagnosis of popliteal artery cystic adventitial disease. We resected the affected popliteal artery with interposition using a right great saphenous vein graft, through a posterior approach. On the fourth postoperative day, he was discharged.Histopathological examination revealed patchy intramural inflammatory infiltrates composed of lymphocytes and rare multinucleated giant cells at the internal lamina and adventitia consistent with a diagnosis of GCA.

CONCLUSION AND RESULT

Our case represents the first reported case of isolated popliteal GCA following vaccination with a COVID-19 mRNA vaccine and COVID-19 infection. We propose that the upregulated immune response to the vaccine acted as a trigger for GCA in this patient with predisposing risk factors and recurrent and repetitive microtrauma in popliteal fossa (the patient is a professional runner). Our case suggests the need for further studies about real world incidence of GCA associated vaccination and COVID-19 infection. Currently, data is limited regarding this relationship. We continue to encourage COVID-19 vaccination, even in elderly patients because the benefits of vaccination far outweigh any theoretical risk of immune dysregulation following administration.

New-Onset Polymyalgia Rheumatica Complicated by Giant Cell Arteritis Following COVID-19 Infection

A 68-year-old female with a past medical history significant for tophaceous gout presented with pain and stiffness in her bilateral shoulders and hip joints for about two weeks after testing positive for COVID-19. Her laboratory results showed an elevated erythrocyte sedimentation rate (ESR) of 74 mm/h and C-reactive protein (CRP) of 25 mg/L. She showed clinical improvement in her symptoms after steroid therapy and was diagnosed with polymyalgia rheumatica (PMR). Despite prompt treatment with steroids, she continued to have persistent joint pain. Also, she developed new bilateral temporal artery tenderness, headaches, blurry vision, and jaw claudication concerning giant cell arteritis (GCA). She was admitted to the hospital for high-dose pulsed IV methylprednisolone and discharged with a steroid taper along with tocilizumab injections. Her symptoms improved rapidly, and she continued to follow up with rheumatology while continuing low-maintenance doses of prednisone. Although the association between PMR and GCA is well-known, the time it takes to reach disease remission, the rate of relapse, and the length of steroid treatment are variable. There are a few COVID-19-associated cases of PMR and GCA; however, the timeline and pathophysiology of this association remain an area for further investigation.

Large-Vessel Giant Cell Arteritis following COVID-19-What Can HLA Typing Reveal?

Giant cell arteritis (GCA) is an immune-mediated vasculitis that affects large arteries. It has been hypothesized that viruses may trigger inflammation within the vessel walls. Genetic studies on human leukocyte antigens (HLAs) have previously reported HLA-DRB1*04 as a susceptible allele for GCA and HLA-DRB1*15 as a protective allele for GCA. Here, we discuss the clinical presentation, laboratory findings, HLA class I and class II analysis results, and management of patients with extracranial large-vessel (LV) GCA, detected at least six weeks after recovery from COVID-19. This case series encompassed three patients with LV-GCA (two males and a female with an age range of 63-69 years) whose leading clinical presentation included the presence of constitutional symptoms and significantly elevated inflammatory markers. The diagnosis of LV-GCA was confirmed by CT angiography and FDG-PET/CT, revealing inflammation in the large vessels. All were treated with corticosteroids, while two received adjunctive therapy. By analyzing HLA profiles, we found no presence of the susceptible HLA-DRB1*04 allele, while the HLA-DRB1*15 allele was detected in two patients. In conclusion, LV-GCA may be triggered by COVID-19. We highlight the importance of the early identification of LV-GCA following SARS-CoV-2 infection, which may be delayed due to the overlapping clinical features of GCA and COVID-19. The prompt initiation of therapy is necessary in order to avoid severe vascular complications. Future studies will better define the role of specific HLA alleles in patients who developed GCA following COVID-19.

Bilateral Axillo-Brachial Artery Stenosis Following Messenger Ribonucleic Acid (mRNA) Vaccination Against Severe Acute Respiratory Coronavirus 2 (COVID-19)

The following case report is an overview of an unusual presentation of bilateral axillo-brachial artery occlusion following messenger ribonucleic acid (mRNA) vaccination against severe acute respiratory coronavirus 2 (COVID-19). A 64-year-old female presented with symptoms initially consistent with polymyalgia rheumatica five weeks following the first booster of the Pfizer-BioNTech COVID-19 vaccine. She was successfully treated with prednisone therapy; however, despite the normalization of inflammatory markers, she later presented with bilaterally occluded axillo-brachial arteries. She successfully underwent endovascular management for the treatment of her symptoms. To our knowledge, this is the first case report of chronically occluded bilateral axillo-brachial artery disease following mRNA vaccination for COVID-19 successfully treated with endovascular therapy. The unusual pathogenesis of upper extremity arterial disease is reviewed and a review of endovascular treatment options is presented. A literature review of the types of vasculitis seen following mRNA COVID-19 vaccination is also presented.

Angioinvasive aspergillosis mimicking giant cell arteritis in an 81-year-old man with jaw pain and vision loss

The present case report focuses on an immunocompromised 81-year-old patient initially diagnosed with Waldenström’s disease. The patient experienced a gradual vision loss and jaw pain with high erythrocyte sedimentation rate. We first suspected giant cell arteritis, despite inconclusive assessment, including a negative temporal artery biopsy. We rapidly started a corticosteroid pulse therapy followed by high-dose corticosteroid therapy that was followed even after discharge from the hospital. The patient was readmitted 20 days later with severe left retro-orbital pain and progressive left vision loss. Clinical examination revealed complete left eyelid ptosis and unilateral blindness with fixed mydriasis and no eye movement. MRI showed signs of ischaemic optic neuropathy with lysis of the left ethmoid sinus wall; thus, indicating ischaemic optic neuropathy related to lymphoplasmacytic infiltration of Waldenström’s disease (Bing-Neel syndrome). Oncological treatment of ibrutinib, a tyrosine kinase inhibitor, was then administered. Despite a favourable prognosis, no improvement was seen. An infectious aetiology was finally confirmed. The left sphenoid sinus biopsy highlighted an angioinvasive aspergillosis with rhino-orbital infiltration observed as ischaemic optic neuropathy. Oncologic treatment was discontinued and antifungal therapy with voriconazole was introduced, leading to a favourable radiological development and analgesic control, without ophtalmological improvement.

Initial anterior uveitis event associated with recent novel SARS-CoV-2 (COVID-19) infection in the setting of HLA-B27

Purpose

To describe an atypical ocular manifestation following SARS-CoV-2 infection.

Observations

A 27-year old previously healthy male with no past ocular history presented with pain, photophobia and red eye in his left eye (OS). His only notable mention on review of systems was a positive SARS-CoV-2 infection three weeks prior. Slit lamp examination demonstrated fine inferior keratic precipitates (KPs) in the inferior cornea and 3+ anterior chamber cells OS. There was no vitritis or chorioretinal lesions. The patient was diagnosed with his first event of acute anterior uveitis. Standard ocular inflammatory panel returned positive for HLA-B27. The postulated mechanism of initial anterior uveitis attack in the setting of COVID-19 infection was dysregulation of inflammatory cells and mediators in a patient with baseline elevated risk for ocular inflammation.

Conclusions and Importance

It is crucial to investigate patients for HLA-B27 following initial anterior uveitis event if infected by SARS-CoV-2, as patients with HLA-B27 are at baseline higher risk of ocular inflammatory dysregulation.

A Case Report of Post COVID19 Giant Cell Arteritis and Polymyalgia Rheumatica With Visual Loss

COVID-19 shares some features of giant-cell arteritis, in which the diagnosis needs a high suspicion for prompt investigation and therapy. When the diseases coexist this might lead to diagnosis delay with grave consequences. We reported a case of a post-COVID-19 giant cell arteritis and polymyalgia rheumatica with visual loss. We treated the patient with pulse methylprednisolone 1 gm daily for 3 consecutive days followed by 60 mg prednisolone for 4 weeks until normalization of ESR, and then, gradual withdrawal. Oral Paracetamol, vitamin-D3, and calcium carbonate were added to the treatment regimen. The headache continued, so, we started perineural injection therapy (PIT) once daily, for 6 sessions, at which the headache was completely resolved after the third injection. The vision was regained completely after the sixth injection.

Arteritic Anterior Ischemic Optic Neuropathy in the Course of Giant Cell Arteritis After COVID-19

Patient: Female, 69-year-old

Final Diagnosis: Anterior ischemic neuropathy • giant cell arteritis

Symptoms: Headache • tenderness • vision loss

Medication: —

Clinical Procedure: —

Specialty: Ophthalmology

New Onset of Autoimmune Diseases Following COVID-19 Diagnosis

There is growing evidence that coronavirus disease 2019 (COVID-19) can lead to a dysregulation of the immune system with the development of autoimmune phenomena. The consequence of this immune dysregulation ranges from the production of autoantibodies to the onset of rheumatic autoimmune disease. In this context, we conducted a systematic review to analyze the current data regarding the new-onset systemic and rheumatic autoimmune diseases in COVID-19 patients. A literature search in PubMed and Scopus databases from December 2019 to September 2021 identified 99 patients that fulfilled the specific diagnostic/classification criteria and/or nomenclature for each rheumatic autoimmune disease. The main diseases reported were vasculitis and arthritis. Idiopathic inflammatory myopathies, systemic lupus erythematosus, and sarcoidosis were also reported in a limited number of patients, as well as isolated cases of systemic sclerosis and adult-onset Still's disease. These findings highlight the potential spectrum of systemic and rheumatic autoimmune diseases that could be precipitated by SARS-CoV-2 infection. Complementary studies are needed to discern the link between the SARS-CoV-2 and new onset-rheumatic diseases so that this knowledge can be used in early diagnosis and the most suitable management.

A Case of Post-COVID-19-Associated Paracentral Acute Middle Maculopathy and Giant Cell Arteritis-Like Vasculitis

ABSTRACT

A 47-year-old man with a history of COVID-19 infection 2 months before presentation, presented with a scotoma of the paracentral visual field of the right eye. After thorough testing and evaluation, a diagnosis of paracentral acute middle maculopathy (PAMM) was established. Two months later, the patient developed temporal headache and jaw claudication. High-dose steroids were initiated, and workup for giant cell arteritis (GCA) was undertaken. The patient experienced resolution of the symptoms within 24 hours of steroid initiation. ESR, CRP, and temporal artery biopsy results were normal, although all were obtained more than 2 weeks after steroid initiation. To the best of our knowledge, our patient represents the first individual to date to potentially implicate COVID-19 in both small and large vessel vasculitis in the ophthalmic setting.