Reactive arthritis after COVID-19 vaccination

Management of postinfectious inflammatory arthritis

PURPOSE OF REVIEW

Postinfectious inflammatory arthritis can result from various pathogens, including bacteria, viruses, fungi, and parasites. Prompt identification and treatment of acute infection is vital, but some cases progress to chronic arthritis despite successful treatment of infection. Postinfectious inflammatory arthritis varies from mild, self-limited arthralgia to severe, refractory arthritis, necessitating ongoing disease-modifying treatment. This review explores the spectrum of postinfectious inflammatory arthritis to provide insights into effective management.

RECENT FINDINGS

Research continues regarding the benefit of antimicrobial therapy, beyond treatment of the acute infection, to diminish the severity of postinfectious inflammatory arthritis. Following treatment of acute infection, most cases are self-limited so treatment is symptomatic. However, a difficult-to-predict fraction of cases develop chronic postinfectious inflammatory arthritis that can be challenging to manage. Recently, as more biologic, and targeted synthetic DMARDs have become available, treatment options have expanded.

SUMMARY

In this article, we use the term 'postinfectious inflammatory arthritis' rather than 'reactive arthritis' because it describes a broader spectrum of diseases and emphasizes the common pathogenesis of a postinfectious inflammatory process. We summarize the conventional therapies and recent management developments for the most frequently encountered postinfectious inflammatory arthritides.

Characteristics of emerging new autoimmune diseases after COVID-19 vaccination: A sub-study by the COVAD group

BACKGROUND

Despite the overall safety and efficacy of COVID-19 vaccinations, rare cases of systemic autoimmune diseases (SAIDs) have been reported post-vaccination. This study used a global survey to analyze SAIDs in susceptible individuals' post-vaccination.

METHODS

A cross-sectional study was conducted among participants with self-reported new-onset SAIDs using the COVID-19 Vaccination in Autoimmune Diseases (COVAD) 2 study dataset-a validated, patient-reported e-survey-to analyze the long-term safety of COVID-19 vaccines. Baseline characteristics of patients with new-onset SAIDs and vaccinated healthy controls (HCs) were compared after propensity score matching based on age and sex in a 1:4 ratio.

RESULTS

Of 16 750 individuals, 74 (median age 52 years, 79.9% females, and 76.7% Caucasians) had new-onset SAID post-vaccination, mainly idiopathic inflammatory myopathies (IIMs) (n = 23, 31.51%), arthritis (n = 15; 20.53%), and polymyalgia rheumatica (PMR) (n = 12, 16.40%). Higher odds of new-onset SAIDs were noted among Caucasians (OR = 5.3; 95% CI = 2.9-9.7; p < .001) and Moderna vaccine recipients (OR = 2.7; 95% CI = 1.3-5.3; p = .004). New-onset SAIDs were associated with AID multimorbidity (OR = 1.4; 95% CI = 1.1-1.7; p < .001), mental health disorders (OR = 1.6; 95% CI = 1.3-1.9; p < .001), and mixed race (OR = 2.2; 95% CI = 1.2-4.2; p = .010), where those aged >60 years (OR = 0.6; 95% CI = 0.4-0.8; p = .007) and from high/medium human development index (HDI) countries (compared to very high HDI) reported fewer events than HCs.

CONCLUSION

This study reports a low occurrence of new-onset SAIDs following COVID-19 vaccination, primarily IIMs, PMR, and inflammatory arthritis. Identified risk factors included pre-existing AID multimorbidity, mental health diseases, and mixed race. Revaccination was well tolerated by most patients; therefore, we recommend continuing COVID-19 vaccination in the general population. However, long-term studies are needed to understand the autoimmune phenomena arising post-vaccination.

Exploring the reported adverse effects of COVID-19 vaccines among vaccinated Arab populations: a multi-national survey study

The coronavirus disease 2019 (COVID-19) pandemic has been a major challenge worldwide for the past years with high morbidity and mortality rates. While vaccination was the cornerstone to control the pandemic and disease spread, concerns regarding safety and adverse events (AEs) have been raised lately. A cross-sectional study was conducted between January 1st and January 22nd, 2022, in six Arabic countries namely Saudi Arabia, Egypt, Syria, Libya, Iraq, and Algeria. We utilized a self-administered questionnaire validated in Arabic which encompassed two main parts. The first was regarding sociodemographic data while the second was about COVID-19 vaccination history, types, doses, and experienced AEs. A multistage sampling was employed in each country, involving the random selection of three governorates from each country, followed by the selection of one urban area and one rural area from each governorate. We included the responses of 1564 participants. The most common AEs after the first and second doses were local AEs (67.9% and 46.6%, respectively) followed by bone pain and myalgia (37.6% and 31.8%, respectively). After the third dose, the most common AEs were local AEs (45.7%) and fever (32.4%). Johnson and Johnson, Sputnik Light, and Moderna vaccines showed the highest frequency of AEs. Factors associated with AEs after the first dose included an increase in age (aOR of 61-75 years compared to the 12-18 years group: 2.60, 95% CI: 1.59-4.25, p = 0.001) and male gender (OR: 0.72, 95% CI: 0.63-0.82, p < 0.001). The cumulative post-vaccination COVID-19 disease was reported with Sinovac (16.1%), Sinopharm (15.8%), and Johnson and Johnson (14.9) vaccines. History of pre-vaccination SARS-CoV-2 infection significantly increases the risk of post-vaccination COVID-19 after the first, second, and booster doses (OR: 3.09, CI: 1.9-5.07, p < 0.0001; OR: 2.56, CI: 1.89-3.47, p < 0.0001; and OR: 2.94, CI: 1.6-5.39, p = 0.0005 respectively). In conclusion, AEs were common among our participants, especially local AEs. Further extensive studies are needed to generate more generalizable data regarding the safety of different vaccines.

Immunologic derangement caused by intestinal dysbiosis and stress is the intrinsic basis of reactive arthritis

Reactive arthritis (ReA) is defined as arthritis resulting from infections in other body parts, such as the gastrointestinal and urogenital tracts. The primary clinical manifestations involve acute-onset and self-limiting asymmetric large joint inflammation in the lower limbs. Although bacterial or chlamydia infections have long been recognized as playing a pivotal role in its pathogenesis, recent studies suggest that antibiotic treatment may perpetuate rather than eradicate chlamydia within the host, indicating an involvement of other mechanisms in Reactive arthritis. Reactive arthritis is currently believed to be associated with infection, genetic marker (HLA-B27), and immunologic derangement. As an autoimmune disease, increasing attention has been given to understanding the role of the immune system in Reactive arthritis. This review focuses on elucidating how the immune system mediates reactive arthritis and explores the roles of intestinal dysbiosis-induced immune disorders and stress-related factors in autoimmune diseases, providing novel insights into understanding reactive arthritis.

Reactive arthritis after vaccination against SARS-CoV-2: A case series and a mini-review

The rapid development of COVID-19 vaccines became essential for addressing the global pandemic. Reactive arthritis after vaccination has been a rare phenomenon. Here, we present a case series of three patients with joint inflammation possibly attributed to COVID-19 immunization (mRNA and live adenovirus vectored vaccine). Symptoms were alleviated using non-steroid anti-inflammatory drugs and glucocorticoids. After follow-up, the patients have not been diagnosed with any other rheumatic disease. Reactive arthritis after the COVID-19 vaccine is an unusual adverse effect and poses a negligible risk in comparison to the benefits of immunization, but it should be considered in differential diagnostics by a practicing rheumatologist who cares for patients with new-onset arthritis without apparent cause at the time of pandemic.

Post-COVID-19 and Post-COVID-19 Vaccine Arthritis, Polymyalgia Rheumatica and Horton's Arteritis: A Single-Center Assessment of Clinical, Serological, Genetic, and Ultrasonographic Biomarkers

The potential role of the COVID-19 vaccine and infection to induce autoimmunity is currently underestimated despite the literature emphasizing arthralgia as a common adverse event. We aimed to study the impact of rheumatological complications post-COVID-19 (PC) and post-COVID-19 vaccine (PCV), comparing undifferentiated arthritis (UA) to Polymyalgia Rheumatica, Horton's Arteritis (PMR-HA) and isolated arthritis to UA with "connective-like" accompanying symptoms. We retrospectively included 109 patients with at least 6 months of follow-up, analyzing serum biomarkers, joint ultrasound (US), lung HRCT, DLCO, and HLA haplotypes. There were 87 UA patients showing increased gastrointestinal and lung involvement (p = 0.021 and p = 0.012), higher anti-spike protein IgG levels (p = 0.003), and anti-SARS-CoV-2 IgG positivity (p = 0.003). Among them, 66 cases progressed to ACR-EULAR 2010 early arthritis after 3 months, whereas PMR-HA patients were more commonly PCV (81.8%, p = 0.008), demonstrating higher CRP (p = 0.007) and ESR (p = 0.006) levels, a lower rate of ANA positivity (p = 0.005), and a higher remission rate after six months (p = 0.050). In UA patients, the prevalent HLA was DRB1*11 and C*07 (36.8% and 42.1%). Serum calprotectin, interleukin-6, and C*07 (p = 0.021, 0.041, 0.018) seemed more specific for isolated UA. Conversely, "connective-like" arthritis showed poorer DLCO (p = 0.041) and more frequent US synovitis (p = 0.041). In conclusion, UA is a frequent common PC and PCV complication and may persist over time when compared to PMR-HA.

New-Onset Rheumatic Immune-Mediated Inflammatory Diseases Following SARS-CoV-2 Vaccinations until May 2023: A Systematic Review

A comprehensive, up-to-date systematic review (SR) of the new-onset rheumatic immune-mediated inflammatory diseases (R-IMIDs) following COVID-19 vaccinations is lacking. Therefore, we investigated the demographics, management, and prognosis of new R-IMIDs in adults following SARS-CoV-2 vaccinations. A systematic literature search of Medline, Embase, Google Scholar, LitCovid, and Cochrane was conducted. We included any English-language study that reported new-onset R-IMID in adults following the post-COVID-19 vaccination. A total of 271 cases were reported from 39 countries between January 2021 and May 2023. The mean age of patients was 56 (range 18-90), and most were females (170, 62.5%). Most (153, 56.5%) received the Pfizer BioNTech COVID-19 vaccine. Nearly 50% of patients developed R-IMID after the second dose of the vaccine. Vasculitis was the most prevalent clinical presentation (86, 31.7%), followed by connective tissue disease (66, 24.3%). The mean duration between the vaccine's 'trigger' dose and R-IMID was 11 days. Most (220, 81.2%) received corticosteroids; however, 42% (115) received DMARDs such as methotrexate, cyclophosphamide, tocilizumab, anakinra, IV immunoglobulins, plasma exchange, or rituximab. Complete remission was achieved in 75 patients (27.7%), and 137 (50.6%) improved following the treatment. Two patients died due to myositis. This SR highlights that SARS-CoV-2 vaccines may trigger R-IMID; however, further epidemiology studies are required.

A case of APMPPE-like panuveitis presenting with extensive outer retinal layer impairment following COVID-19 vaccination

BACKGROUND

Vaccination against the worldwide pandemic coronavirus disease 2019 (COVID-19) is underway; however, some cases of new onset uveitis after vaccination have been reported. We report a case of bilateral acute posterior multifocal placoid pigment epitheliopathy-like (AMPPE-like) panuveitis after COVID-19 vaccination in which the patient's pathological condition was evaluated using multimodal imaging.

CASE PRESENTATION

A 31-year-old woman experienced bilateral hyperemia and blurred vision starting 6 days after her second inoculation of the COVID-19 vaccination. At her first visit, her visual acuity was decreased bilaterally, and severe bilateral anterior chamber inflammation and bilateral scattering of cream-white placoid lesions on the fundus were detected. Optical coherence tomography (OCT) showed serous retinal detachment (SRD) and choroidal thickening in both eyes (OU). Fluorescein angiography (FA) revealed hypofluorescence in the early phase and hyperfluorescence in the late phase corresponding to the placoid legions. Indocyanine green angiography (ICGA) showed sharply marginated hypofluorescent dots of various sizes throughout the mid-venous and late phases OU. The patient was diagnosed with APMPPE and was observed without any medications. Three days later, her SRD disappeared spontaneously. However, her anterior chamber inflammation continued, and oral prednisolone (PSL) was given to her. Seven days after the patient's first visit, the hyperfluorescent lesions on FA and hypofluorescent dots on ICGA partially improved; however, the patient's best corrected visual acuity (BCVA) recovered only to 0.7 OD and 0.6 OS, and the impairment of the outer retinal layer was broadly detected as hyperautofluorescent lesions on fundus autofluorescence (FAF) examination and as irregularity in or disappearance of the ellipsoid and interdigitation zones on OCT, which were quite atypical for the findings of APMPPE. Steroid pulse therapy was performed. Five days later, the hyperfluorescence on FAF had disappeared, and the outer retinal layer improved on OCT. Moreover, the patient's BCVA recovered to 1.0 OU. Twelve months after the end of treatment, the patient did not show any recurrences.

CONCLUSIONS

We observed a case of APMPPE-like panuveitis after COVID-19 vaccination featuring some atypical findings for APMPPE. COVID-19 vaccination may induce not only known uveitis but also atypical uveitis, and appropriate treatment is required for each case.

New-Onset Arthritis Following COVID-19 Vaccination: A Systematic Review of Case Reports

Coronavirus disease 2019 (COVID-19) vaccine has effectively suppressed the spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and alleviated its symptoms, but there are also many adverse events. Joint diseases caused by COVID-19 vaccine have been reported in many studies. Some are well-controlled arthritis patients who developed arthritis after COVID-19 vaccination, while others are new-onset joint pain and swelling problems after COVID-19 vaccination. The purpose of this systematic review is to examine the literature reports in existing databases and analyze the incidence of new-onset arthritis after COVID-19 vaccination. We included 31 eligible articles and described 45 patients, ranging in age from 17 to over 90, with more females than males. The majority (84.4%) of patients received the adenovirus vector vaccine (ChAdOx1) and the mRNA-based vaccine (BNT126b2 and mRNA-1273). Most (64.4%) patients developed joint-related symptoms after the first dose of vaccine, and 66.7% developed symptoms within the first week of vaccination. The joint symptoms involved were mainly joint swelling, joint pain, limited range of motion, and so on. A total of 71.1% of the patients involved multiple joints, both large and small; 28.9% of patients involved only a single joint. Some (33.3%) patients were confirmed by imaging, and the most common diagnoses were bursitis and synovitis. Two nonspecific inflammatory markers, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), were monitored in almost all cases, and all patients showed varying degrees of increase in these two markers. Most of the patients received the treatment of glucocorticoid drugs or nonsteroidal anti-inflammatory drugs (NSAIDs). Clinical symptoms markedly improved in most patients, with 26.7% making a full recovery and no relapse after a few months of follow-up. To determine whether there is a causal relationship between COVID-19 vaccination and the triggering of arthritis, large-scale and well-controlled research studies are needed in the future to verify this relationship and to further study its pathogenesis in detail. Clinicians should raise awareness of this complication with a view to early diagnosis and appropriate treatment.

A Case Report of Reactive Arthritis After COVID-19 AstraZeneca Vaccination

In early 2021, multiple vaccinations for the coronavirus disease 2019 (COVID-19) in various immunological formulations were administered successfully to humans worldwide. Although numerous encountered side effects were expected, there were some effects that were unexpected. We report a case of a patient who experienced a rare occurrence of reactive arthritis in the right knee joint that manifested insidiously as pain, heat, and swelling on the second day following vaccination with the Oxford-AstraZeneca COVID-19 vaccine. The patient underwent a series of investigations, confirming the suspected diagnosis and ruling out other possible diseases. The case was refractory to oral non-steroidal anti-inflammatory drugs. Thus, the treatment was shifted to intra-articular steroids. Although the treatment plan improved the symptoms of the patient noticeably, it did not resolve them. A rare possible side effect following COVID-19 vaccination is reactive arthritis, which often occurs in young and healthy individuals with no significant comorbidities.

Case Report: Acquired Brown Syndrome after COVID-19 Vaccination

SIGNIFICANCE

Brown syndrome, or superior oblique tendon sheath syndrome, is characterized by limitation of elevation on adduction. The disorder is thought to involve the trochlea/superior oblique tendon complex through traumatic, surgical, and inflammatory mechanisms. It could be an indication of multiple underlying immunological or rheumatological disorders.

PURPOSE

This study aimed to report an unusual strabismus after receiving the first dose of a live attenuated coronavirus disease 2019 (COVID-19) vaccine.

CASE REPORT

A 31-year-old female patient presented with painful vertical diplopia and tenderness of the left trochlear area 3 days after the first dose of COVID-19 vaccination. She had a compensatory chin elevation and face turn to the right, as well as a left 10-prism-diopter hypotropia in the primary position, which increased to 15 prism diopters in the right gaze and disappeared in the left gaze. Ocular motility revealed the limitation of elevation on adduction. The patient denied any history of ocular trauma and was consequently investigated for dysthyroid disease and various immunological and rheumatological disorders, which were excluded. A Hess chart was obtained to document the motility disorder.

CONCLUSIONS

We report a case of acquired Brown syndrome in a 31-year-old otherwise healthy woman shortly after COVID-19 vaccination. It is possible that the patient may have developed trochleitis and/or superior oblique tenosynovitis brought on by cross-reacting antibodies generated by the immune response to the vaccine. In the age of the widest vaccination campaign in human history, it is highly likely that we will continue to observe many unexpected potential adverse effects of these vaccines in our clinical practice.

Efficacy and risk of mRNA vaccination in patients with autoimmune inflammatory rheumatic diseases

Coronavirus disease 2019 (COVID-19), which spread worldwide from Wuhan, China, in 2019, appeared for a time to be overcome by the remarkable efficacy of mRNA vaccines; however, new variants of severe acute respiratory syndrome coronavirus 2 have emerged and remain rampant. The involvement of the virus in the emergence of variant strains and the relationship between vaccine efficacy and immunosuppressive drugs have attracted significant attention, particularly with regard to patients with autoimmune inflammatory rheumatic disease (AIRD) who take immunosuppressive drugs. This review outlines the relationship between mRNA vaccines, one of the key strategies against COVID-19, and AIRD and discusses the immune response elicited by mRNA vaccines. Furthermore, the impact of immunosuppressive agents on the mRNA vaccine-induced immune response in patients with AIRD and side effects of the vaccine, such as exacerbation of the underlying disease, is outlined.

Systemic lupus erythematosus and antiphospholipid syndrome after COVID-19 vaccination. A case report

Coronavirus disease 2019 (COVID-19) vaccines have some adverse effects, mostly mild. However, by presenting an immunological challenge to the individual, they could infrequently trigger immune-mediated diseases (IMDs). We report the case of a 42-year-old woman, with no previous medical history, who received the first dose of vaccine against COVID-19 and developed inflammatory arthralgias, associated with sudden-onset dyspnoea and hypoxemia. Pulmonary thromboembolism was documented, and the diagnosis of systemic lupus erythematosus (SLE) and secondary antiphospholipid syndrome (APS) was suspected. Autoantibodies were measured confirming this suspicion. After a few days, she presented a massive pericardial effusion with cardiac tamponade that required surgical management. Treatment with azathioprine, hydroxychloroquine, corticosteroids, and anticoagulation was indicated with improvement of all her symptoms. There is controversy regarding the potential of COVID-19 vaccines to induce autoimmunity. Studies addressing the safety of using these vaccines have reported the occurrence of mild local and systemic reactions, most frequently in young adults. So far, there are few reports of patients who have developed autoimmune or autoinflammatory diseases after getting vaccinated with any of the COVID-19 vaccines. To the best of our knowledge, to date, this is one of the first cases of new-onset SLE and secondary APS after COVID-19 vaccination.

Prolonged peripheral seronegative spondyloarthritis following BioNTech coronavirus disease 2019 vaccination: A case report

A female 17-year-old diagnosed with seronegative spondyloarthritis (SpA) following the first jab of the BioNTech162b2 (BNT162b2) vaccine presented with recurrent swelling and painful knee accompanied by posterior heel tenderness over the past 1.5 months. Laboratory investigations revealed elevated serum erythrocyte sedimentation rate and C-reactive protein. Synovial aspiration yielded level 3 crystal-free, aseptic and inflammatory effusion. She tested positive for the human leukocyte antigen-B27 and was diagnosed with peripheral SpA. She received daily celecoxib (400 mg), methylprednisolone (8 mg), and sulfasalazine (2 g), but the effect was limited. Nonetheless, her symptoms improved significantly with weekly subcutaneous etanercept administration (50 mg). Four weeks later, her arthritis was completely resolved. To our knowledge, this is the first case report of newly diagnosed seronegative peripheral SpA in an autoimmunity-disease-free individual following messenger RNA BNT coronavirus disease 2019 vaccination.

CoronaVac: A review of efficacy, safety, and immunogenicity of the inactivated vaccine against SARS-CoV-2

CoronaVac, also known as the Sinovac inactivated SARS-CoV-2 vaccine, has been widely implemented in combating the COVID-19 pandemic. We summarized the results of clinical trials and real-world studies of CoronaVac in this review. The overall efficacy for the prevention of symptomatic COVID-19 (before the emergence of variants of concern) using two doses of 3 μg CoronaVac was 67.7% (95% CI, 35.9% to 83.7%). Effectiveness in preventing hospitalizations, ICU admissions, and deaths was more prominent than that in preventing COVID-19. A third dose inherited the effectiveness against non-variants of concern and increased effectiveness against severe COVID-19 outcomes caused by omicron variants compared to two doses. Most adverse reactions were mild. Few vaccine-related serious adverse reactions have been reported. Moreover, three-dose regimen significantly increased the seroconversion levels of neutralizing antibodies against omicron as compared to two-dose regimen. This review of CoronaVac may provide a scientific basis for optimizing global immunization strategies.

New-onset inflammatory arthritis after COVID-19 vaccination: A systematic review

AIM

To analyze the clinical patterns of new-onset inflammatory arthritis after COVID-19 vaccination among patients without pre-existing rheumatic or autoimmune diseases.

METHOD

Case reports and series of new-onset inflammatory arthritis after COVID-19 vaccination were collected before April 2022. Clinical characteristics including diagnosis, age, gender, vaccine types, time interval between events, joint involvement (poly- or oligo-/monoarthritis), and laboratory data reflecting inflammatory status were sorted and P values between these parameters are calculated with independent sample Student's t test or 2 × 2 Fisher's exact test.

RESULTS

Among 39 cases with new-onset post-vaccination arthritis including 25 females and 13 males (1 unknown), the most common diagnosis is adult-onset Still's disease (AoSD, 10 cases), and the most common vaccine types are BNT162b2 (16 cases) and AZD-1222 (or ChAdOx1-nCoV19, 15 cases). Sub-analysis reveals that post-vaccination polyarthritis is more common among females (P = .016, by 2 × 2 Fisher's exact test, compared with male patients) and older patients (P = .006, by Student's t test). The C-reactive protein level is significantly higher in cases with post-vaccination inflammatory polyarthritis than oligoarthritis (P = .029), as well as in cases with AoSD than other causes of post-vaccination arthritis (P = .004). However, serum level of erythrocyte sedimentation rate in patients with post-vaccination AoSD are independent of other clinical variables in the analysis.

CONCLUSION

New-onset post-vaccination polyarthritis are more common in females and older patients. Although COVID-19 vaccines may lead to inflammatory arthritis, the benefits of vaccination substantially outweigh the potential risks of such serious adverse effects due to their rarity.

COVID-19 Vaccination Trends and Side Effects among Egyptian Hemodialysis Patients: A Multicenter Survey Study

(1) Background: Vaccination may be a key intervention to prevent infection in chronic hemodialysis (CHD) patients. This study aimed to determine the COVID-19 vaccination status in Egyptian CHD patients and to analyze the safety and detailed side effect profile of the COVID-19 vaccine among these patients. (2) Methods: This survey-based study was conducted on 670 end-stage renal disease (ESRD) patients on CHD from 3 December 2021 to 5 February 2022. Subjects were asked about sociodemographic characteristics, clinical and therapeutic data, in addition to their COVID-19 vaccination status. If the subject had been vaccinated, we inquired about the type of vaccine and the side effects that occurred within a few days after administration of the first and second dose of the COVID-19 vaccine. Additionally, subjects were asked about the onset of side effects (days from vaccination), timing of maximum symptoms, intensity of symptoms and their effect on activity and need for medical attention. (3) Results: The study included 670 CHD patients with a mean age of 50.79 years; 58.1% were females. The vast majority (614; 91.6%) of the studied patients received two doses of the vaccine. Side effects were more commonly reported after the first dose than the second dose. The main side effects reported were generalized weakness/fatigue (56%), headache (43.8%) and fever (40.4%), and sore arm/pain was also reported (29.3%). Adverse events mostly occurred within one day after vaccination and the maximum symptoms usually happened on the second day. The median duration of symptoms was 3 days with a maximum duration up to 5 days. The univariate logistic regression analysis showed that male gender (OR 1.848; (95% CI, 1.242−2.749), p = 0.002), age (OR 0.981; (95% CI, 0.969−0.993), p = 0.003), smoking (OR 6.067; (95% CI, 3.514−10.475), p < 0.001), duration since starting HD (OR 0.998; (95% CI, 0.998−0.999), p < 0.001), associated comorbidities (OR 2.202; (95% CI, 1.478−3.281), p < 0.001) and prior COVID-19 infection (OR 3.318; (95% CI, 1.952−5.642), p < 0.001) were the main determinants of adverse events related to COVID-19 vaccination. (4) Conclusions: our preliminary findings support the favorable short-term safety profile of the COVID-19 vaccine among CHD patients, and hence can reassure both clinicians and patients, as well as further promote COVID-19 vaccine administration among these patients.

Corona Virus Disease-19 Vaccine-associated Autoimmune Disorders

Coronavirus disease is a highly infectious viral disease caused by severe acute respiratory syndrome virus (SARS nCoV2). It was declared a pandemic within a few months of identification of its index case. The spread of COVID-19 across the globe was rampant, overwhelming healthcare systems and crippling global economies. Since the world was caught off guard by the pandemic, vaccine programs had to be rolled out in emergency to curb its spread. Ten vaccines have been granted Emergency Use Authorization thus far. Much of the side effects we know today are post-marketing adverse effects. Most of them are mild like myalgia and injection-site reactions, but a few of them such as post-vaccination autoimmune diseases have alerted the medical community. These include vaccine-induced thrombotic thrombocytopenia, autoimmune hepatitis, myocarditis, and Graves' disease. We attempt to summarize the diverse autoimmune phenomena reported after COVID-19 vaccination, with an aim to sensitize the medical community so that they can be better equipped in management when confronted with these diseases. This review by no means refutes the potential benefit of COVID-19 vaccination which has consolidated its place in preventing infections and substantially reducing severity and mortality.

Do we miss rare adverse events induced by COVID-19 vaccination?

Although severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has caused many complications, the invention of coronavirus disease 2019 (COVID-19) vaccines has also brought about several adverse events, from common side effects to unexpected and rare ones. Common vaccine-related adverse reactions manifest locally or systematically following any vaccine, including COVID-19 vaccines. Specific side effects, known as adverse events of particular interest (AESI), are unusual and need more evaluation. Here, we discuss some of the most critical rare adverse events of COVID-19 vaccines.

Autoimmune and autoinflammatory conditions after COVID-19 vaccination. New case reports and updated literature review

Autoimmunity linked to COVID-19 immunization has been recorded throughout the pandemic. Herein we present six new patients who experienced relapses of previous autoimmune disease (AD) or developed a new autoimmune or autoinflammatory condition following vaccination. In addition, we documented additional cases through a systematic review of the literature up to August 1st, 2022, in which 464 studies (928 cases) were included. The majority of patients (53.6%) were women, with a median age of 48 years (IQR: 34 to 66). The median period between immunization and the start of symptoms was eight days (IQR: 3 to 14). New-onset conditions were observed in 81.5% (n: 756) of the cases. The most common diseases associated with new-onset events following vaccination were immune thrombocytopenia, myocarditis, and Guillain-Barré syndrome. In contrast, immune thrombocytopenia, psoriasis, IgA nephropathy, and systemic lupus erythematosus were the most common illnesses associated with relapsing episodes (18.5%, n: 172). The first dosage was linked with new-onset events (69.8% vs. 59.3%, P = 0.0100), whereas the second dose was related to relapsing disease (29.5% vs. 59.3%, P = 0.0159). New-onset conditions and relapsing diseases were more common in women (51.5% and 62.9%, respectively; P = 0.0081). The groups were evenly balanced in age. No deaths were recorded after the disease relapsed, while 4.7% of patients with new-onset conditions died (P = 0.0013). In conclusion, there may be an association between COVID-19 vaccination and autoimmune and inflammatory diseases. Some ADs seem to be more common than others. Vaccines and SARS-CoV-2 may induce autoimmunity through similar mechanisms. Large, well-controlled studies are warranted to validate this relationship and assess additional variables such as genetic and other environmental factors.

COVID-19 and rheumatic diseases: A mini-review

Joint pain and arthralgia can be manifestations of COVID-19, and studies evaluating long COVID symptoms identified the persistence of these disorders. Moreover, some case reports highlighted the development of new inflammatory arthritis in patients with COVID-19, suggesting a possible relation. Viral infections and rheumatic diseases share a documented relationship; they have been associated with genetic and environmental risk factors responsible for some of them. There is crosstalk between viruses and the immune system during the development of several rheumatic diseases. Moreover, infections may participate in the pathogenesis of autoimmune rheumatic diseases and contribute to patient mortality. Therefore, it is crucial to provide a clearer insight into the interaction between viral infections and rheumatic diseases. Here, we provide a mini-review of the current literature with the aim of shedding light on the relationship between COVID-19 and rheumatic or musculoskeletal diseases, which is still unclear. Specifically, we examined several aspects: risk for the rheumatic population of acquiring the virus or developing severe symptoms, similarities of COVID-19 and arthritis, the possible rheumatic consequence of COVID-19, of rheumatic drugs and vaccines, and COVID-19 prevention in rheumatic patients through vaccination.

HLA-B27 negative reactive arthritis versus HLA-B27 positive reactive arthritis: A retrospective study

Reactive arthritis (ReA) is defined as inflammatory arthritis secondary to an extra-articular infection with a key genetic background, HLA-B27. However, to date, the diagnosis and classification remain incomplete. The study focused on the similarities and differences in clinical manifestation, imaging features, and laboratory inspection between HLA-B27 negative patients and HLA-B27 positive patients in order to provide a reference for future development of diagnostic and classification criteria. Twenty-five ReA (19 HLA-B27 negative patients and 6 HLA-B27 positive patients) were included in this retrospective study. Clinical data, including demographics, clinical symptoms, imaging features, and laboratory inspection, were collected. The chi-square test and Mann-Whitney U test were used in the analysis. HLA-B27 negative group showed more involvement of upper extremities and small joints, while HLA-B27 positive group performed more axial symptoms. No significant difference was found in imaging features (ultrasound and magnetic resonance imaging) or laboratory inspection (microbes culture and infection-related indicators) between the 2 groups. ReA patients with different genetic backgrounds show various manifestations, although they encounter similar infections.

Assessment of risk factors in post- COVID-19 patients and its associated musculoskeletal manifestations: A cross-sectional study in India

INTRODUCTION

Musculoskeletal manifestations of COVID-19, post COVID-19, and post COVID-19 vaccination include arthralgia, myalgia, new-onset backache, fatigue, inflammatory arthritis either symmetrical or polyarticular, reactive arthritis, osteoporosis, osteonecrosis of the femoral head, neuropathies, myositis, and myopathies. Almost 15% and 44% of post-COVID-19 patients reported arthralgia and myalgia. We aim to analyze the musculoskeletal manifestations of COVID-19 infection and the factors determining their severity.

METHODOLOGY

This is a retrospective multicentric cross-sectional study conducted from all the four regions (northern, southern, eastern, and western regions) in India. The recruitment period was from June 1st, 2021, to September 30th, 2021. All patients with COVID-19 positivity in the past were classified into three groups (mild, moderate, and severe). The primary outcome is to find the correlation of musculoskeletal symptoms with disease positivity, severity, and demographic variables. We focused at clinical characteristics and symptoms at the time of admission, as well as comorbidities, laboratory findings, immunological findings, treatments, and outcomes.

RESULTS

The study was conducted among 2334 subjects across all the regions of India. Out of which 719 were COVID-19 positive individuals. Non-vaccinated were about 62.6% compared to 37.4% vaccinated among COVID-19 positive individuals. The total average musculoskeletal scores calculated were about 15.94 ± 54.86. MSK scores were significantly higher (p < 0.001) among males, uneducated, those with co-morbidities, and non-vaccinated individuals. Multivariate regression analysis showed a 1.63 times higher risk of having COVID-19 infection among smokers, those who don't exercise regularly are 1.25 times at risk of having COVID-19 infection. Similarly, those who have comorbidities are 1.93 times at risk of having COVID-19 infection. Non-vaccinated individuals were 2.33 times at risk of having COVID-19 infection.

CONCLUSION

Factors such as male sex, non-vaccination, and associated co-morbidities increased the risk of developing severe MSK manifestations upon infection with COVID-19 and needs extended monitoring to control the morbidity due to the same.

COVID-19 Vaccine Clinical Trials: A Bird’s Eye Perspective

Several Phase-III clinical studies investigating vaccine safety and effectiveness have been published a year following the first breakout of the COVID-19 pandemic. These vaccine candidates were produced using a variety of vaccination technologies, including mRNA, recombinant protein, adenoviral vector, and inactivated virus-based platforms, by various research organizations and pharmaceutical firms. Despite many successful clinical studies, participants are restricted by trial inclusion and exclusion criteria, geographic location, and the current state of the virus epidemic. Many concerns remain, particularly for specific populations such as the elderly, women who are pregnant or nursing, and teenagers. Vaccine effectiveness against asymptomatic infection and particular viral variations, on the other hand, is still largely unclear. This review will focus on vaccination candidates that have completed Phase-III clinical trials and will examine the scientific evidence that has been gathered so far for these vaccine candidates for various subgroups of individuals and virus variations.

Reactive synovitis of the knee joint after COVID-19 vaccination: The first ultrastructural analysis of synovial fluid

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the resulting coronavirus 2019 disease (COVID-19) have spread all around the world since 2019 and have affected millions of people. The development of COVID-19 vaccines helped to decelerate the spread of the virus. However, as in the case of vaccines against other infectious diseases, adverse events can also present with COVID-19 vaccines.

CASE PRESENTATION

We report here a rare case of a 53-year-old man with knee-joint synovitis, after the first dose of messenger RNA vaccine, with no fever and a negative COVID-19 reverse transcription polymerase chain reaction test. During a clinical examination the suspicion of pyogenic arthritis was excluded by blood tests and by a complex joint effusion examination, including a microbiological and cytological-energy analysis of the synovial fluid. The treatment received by our patient consisted of 3 doses of dexamethasone administered intravenously over a period of 3 days. All the symptoms improved after this therapy, and in the 3-week follow-up period we recorded full recovery with no consequences.

CONCLUSION

Case reports on patients undergoing COVID-19 vaccination should be examined in order to detect rare and long-term side-effects. This is the first report to present the outcomes of an ultrastructural analysis of post-vaccination synovitis.

COVID-19 disease and autoimmune disorders: A mutual pathway

Coronavirus disease 2019 (COVID-19) is a real challenge for humanity with high morbidity and mortality. Despite being primarily a respiratory illness, COVID-19 can affect nearly every human body tissue, causing many diseases. After viral infection, the immune system can recognize the viral antigens presented by the immune cells. This immune response is usually controlled and terminated once the infection is aborted. Nevertheless, in some patients, the immune reaction becomes out of control with the development of autoimmune diseases. Several human tissue antigens showed a strong response with antibodies directed against many severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) proteins, such as SARS-CoV-2 S, N, and autoimmune target proteins. The immunogenic effects of SARS-CoV-2 are due to the sizeable viral RNA molecules with interrupted transcription increasing the pool of epitopes with increased chances of molecular mimicry and interaction with the host immune system, the overlap between some viral and human peptides, the viral induced-tissue damage, and the robust and complex binding between sACE-2 and SARS-CoV-2 S protein. Consequently, COVID-19 and its vaccine may trigger the development of many autoimmune diseases in a predisposed patient. This review discusses the mutual relation between COVID-19 and autoimmune diseases, their interactive effects on each other, the role of the COVID-19 vaccine in triggering autoimmune diseases, the factors affecting the severity of COVID-19 in patients suffering from autoimmune diseases, and the different ways to minimize the risk of COVID-19 in patients with autoimmune diseases.

COVID-19 Vaccine-Related Arthritis: A Descriptive Study of Case Reports on a Rare Complication

Large-scale coronavirus disease 2019 (COVID-19) vaccination programs have been rolled out worldwide. Vaccines that are widely used globally include mRNA vaccines, adenoviral vector vaccines, and inactivated whole-virus vaccines. COVID-19 vaccines can lead to varying side effects. Among the most common of these adverse effects are pain at the injection site, fatigue, and headaches. Some side effects, however, are not very well documented, and these include joint-related adverse effects. In this review, we assess the epidemiology and clinical features of post-COVID-19 vaccination joint-related adverse effects based on the analysis of 16 patient case reports.

Based on our analysis, we found that females formed the majority of the cases, accounting for 62.5% of patients, while 37.5% of the cases were males. The mean age of presentation among the patients was 54.8 years, with a standard deviation (SD) of 17.49 years. In 37.5% of the cases, patients received the Sinovac vaccine. The proportion of patients who received other vaccines was as follows: the Pfizer vaccine: 31.25%; Sputnik V: 12.5%; Moderna, AstraZeneca, and Covaxin: 6.25% each.

The characteristics of joint-related adverse effects following COVID-19 vaccination were analyzed in this study. We identified several key findings related to factors such as age, gender, type of vaccine, clinical features, and diagnosis modality. Our analysis showed that more cases were reported among individuals who received the Sinovac vaccine, as compared to the others. Further research is required to examine the underlying cause of this association.

Case of reactive sacroiliitis possibly induced by an mRNA coronavirus disease vaccine

A woman in her 30s received a second dose, first booster, Corminaty vaccine against the SARS-CoV-2. Three days later, the patient developed unilateral sacroiliitis. A pelvic scan revealed inflammatory joint edges, bone erosion and a heterogeneous mass of 2.5 cm in the psoas muscle. Joint puncture revealed no microcrystalline deposits, but bone marrow cells, erythroblast were identified. The standard bacterial cultures and culture for mycobacteria were negative. HLA B27 was negative, and no seroconversion was identified for HIV, Epstein-Barr virus, cytomegalovirus, chlamydia or Quantiferon. Two months later, the sacroiliitis resolved.The aetiologic approach of this erosive unilateral acute sacroiliitis in a person naïve to rheumatologic pathology was negative for inflammatory or infectious sacroiliitis. Arthralgias after vaccination are expected. Arthritis is less common, and acute sacroiliitis has not yet been described. Acute sacroiliitis may be considered a reactive sacroiliitis to the anti-COVID-19 mRNA vaccine.

Covid-19 vaccines and variants of concern: A review

Since the outbreak of coronavirus disease 2019 (Covid-19) in December 2019, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the number of confirmed infections has risen to more than 242 million worldwide, with nearly 5 million deaths. Currently, nine Covid-19 vaccine candidates based on the original Wuhan-Hu-1 strain are at the forefront of vaccine research. All nine had an efficacy over 50% against symptomatic Covid-19 disease: NVX-CoV2373 (∼96%), BNT162b2 (∼95%), mRNA-1273 (∼94%), Sputnik V (∼92%), AZD1222 (∼81%), BBIBP-CorV (∼79%), Covaxin (∼78%), Ad26.CoV.S (∼66%) and CoronaVac (∼51%). However, vaccine efficacy (VE) can be jeopardised by the rapid emergence and spread of SARS-CoV-2 variants of concern (VOCs) that could escape from neutralising antibodies and/or cell-mediated immunity. Rare adverse events have also been reported soon after administration of viral vector and mRNA vaccines. Although many Covid-19 vaccines have been developed, additional effective vaccines are still needed to meet the global demand. Promising Covid-19 vaccines such as WIBP-CorV, AD5-nCOV, ZyCoV-D, CVnCoV, EpiVacCorona and ZF2001 have advanced to clinical studies. This review describes the most relevant mutations in the SARS-CoV-2 spike protein, discusses VE against VOCs, presents rare adverse events after Covid-19 vaccination and introduces some promising Covid-19 vaccine candidates.

Monoarthritis induced by the Oxford-AstraZenecaR SARS-CoV-2 vaccine

We describe the case of a 25-year-old woman who presented with monoarthritis of the proximal interphalangeal articulation of the fourth left finger 4 days after receiving the second dose of the Oxford-AstraZeneca^R SARS-CoV-2 vaccine. She had no abnormalities in her X-ray or blood exams, but she had a cousin diagnosed with juvenile rheumatoid arthritis. The patient had an excellent response to anti-inflammatory medication, the arthritis was transient and left no sequelae. Studies have shown some vaccines may be associated with acute arthritis, in particular the measles–mumps–rubella vaccine. Young women such as our patient seem to be more susceptible to post-vaccination arthritis. Most of the cases reported were transient and left no articular sequelae, thus we did not contraindicate further doses of the Oxford-AstraZeneca^R SARS-CoV-2 vaccine (should they be recommended in the future) in this case.

COVID-19 vaccination-related small vessel vasculitis with multiorgan involvement

Since its first outbreak in 2019, coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2, has been ongoing, and the pandemic is not over yet. Vaccines developed against COVID-19 have been approved and widely used since 2020; however, vaccine safety concerns need to be addressed. Autoimmune symptoms have been reported as a side effect of many COVID-19 vaccines. In particular, several cases of COVID-19 vaccine-induced vasculitis have recently been reported. Herein, we report the case of a 77-year-old woman who developed small-vessel vasculitis with multiorgan involvement after receiving the BNT162b2 COVID-19 vaccine (Pfizer and BioNTech, New York City, NY, USA).

Two-dose COVID-19 vaccination and possible arthritis flare among patients with rheumatoid arthritis in Hong Kong

OBJECTIVES

To investigate the relationship between COVID-19 full vaccination (two completed doses) and possible arthritis flare.

METHODS

Patients with rheumatoid arthritis (RA) were identified from population-based electronic medical records with vaccination linkage and categorised into BNT162b2 (mRNA vaccine), CoronaVac (inactive virus vaccine) and non-vaccinated groups. The risk of possible arthritis flare after vaccination was compared using a propensity-weighted cohort study design. We defined possible arthritis flare as hospitalisation and outpatient consultation related to RA or reactive arthritis, based on diagnosis records during the episode. Weekly prescriptions of rheumatic drugs since the launch of COVID-19 vaccination programme were compared to complement the findings from a diagnosis-based analysis.

RESULTS

Among 5493 patients with RA (BNT162b2: 653; CoronaVac: 671; non-vaccinated: 4169), propensity-scored weighted Poisson regression showed no significant association between arthritis flare and COVID-19 vaccination ((BNT162b2: adjusted incidence rate ratio 0.86, 95% Confidence Interval 0.73 to 1.01); CoronaVac: 0.87 (0.74 to 1.02)). The distribution of weekly rheumatic drug prescriptions showed no significant differences among the three groups since the launch of the mass vaccination programme (all p values >0.1 from Kruskal-Wallis test).

CONCLUSIONS

Current evidence does not support that full vaccination of mRNA or inactivated virus COVID-19 vaccines is associated with possible arthritis flare.

Reactive arthritis before and after the onset of the COVID-19 pandemic

Most accepted definitions of reactive arthritis (ReA) consider it a type of spondyloarthritis (SpA) precipitated by a gut or urogenital infection. A wider definition considers any arthritis that occurs after a mucosal surface infection as ReA. There is limited consensus regarding a working definition, status of HLA-B27, or even classification criteria for ReA. This may also contribute to a lack of systemic studies or clinical trials for ReA, thereby reducing further treatment recommendations to expert opinions only. The emergence of post-COVID-19 ReA has brought the focus back on this enigmatic entity. Post-COVID-19 ReA can present at extremes of age, appears to affect both sexes equally and can have different presentations. Some present with small joint arthritis, others with SpA phenotype-either with peripheral or axial involvement, while a few have only tenosynovitis or dactylitis. The emergence of post-vaccination inflammatory arthritis hints at similar pathophysiology involved. There needs to be a global consensus on whether or not to include all such conditions under the umbrella of ReA. Doing so will enable studies on uniform groups on how infections precipitate arthritis and what predicts chronicity. These have implications beyond ReA and might be extrapolated to other inflammatory arthritides.

Key Points

• Classical reactive arthritis (ReA) has a spondyloarthritis phenotype and is preceded by symptomatic gut or urogenital infection

• The demonstration of antigen and nucleic acid sequences of pathogens in synovium has blurred the difference between invasive arthritis and reactive arthritis

• Post-COVID-19 ReA has a transient phenotype and can have different presentations. All reported cases are self-limiting

• The large amount of literature reporting post-COVID-19 ReA calls for introspection if the existing definitions of ReA need to be updated.

Diffuse cutaneous systemic sclerosis following SARS-Co V-2 vaccination

The largest world-wide vaccination rollout ever is currently underway to tackle the covid-19 pandemic. We report a case of diffuse cutaneous systemic sclerosis (SSc) in a 70-year-old male with rapidly progressive skin thickening which developed two weeks after receiving the first dose of the ChAdOx1 nCOV-19 vaccine. As the onset of SSc skin was in close temporal proximity to the administration of the first dose vaccine with no other triggers, we suspected a possible adverse reaction to the ChAdOx1 nCOV-19 vaccine. We hypothesise that the recombinant adenoviral vector encoding the spike protein antigen of SARS-CoV-2 triggered an unexpected immune activation resulting in an atypical presentation of late-onset SSc, within the well-recognised ANA positive, ENA negative subgroup of patients.We review the possible mechanisms underlying autoimmunity when provoked by vaccination and other published rheumatological phenomenon occurring shortly after COVID vaccination.

Reactive arthritis (ReA) following the first dose of Covid-19 vaccine; A case report

Introduction: The development of vaccination against COVID-19 infection was a promising step during the battle against this pandemic; however, some vaccines were associated with some complications starting with just flu-like symptoms up to anaphylaxis; of the reported complications is joints pain. Here, we report a case who developed reactive arthritis (ReA) after receiving the first dose of the Pfizer-BioNTech Covid-19 vaccine. Case presentation: A healthy 54 years old male with no previous history of any medical condition was presented with bilateral hand and bilateral knee pain after one week of receiving his first dose of Pfizer-BioNTech Covid-19 vaccine. Clinical examination revealed swelling, tenderness, and erythema over the right index metacarpophalangeal joint and the medial aspect of the right knee. Radiographs of the hand and knee were normal. Laboratory investigations were within normal values except for an elevated ESR (15 mm/hr.) and a positive CRP titer of 48 mg/l. The symptoms entirely resolved after two weeks of non-steroidal anti-inflammatory medications. Conclusions: Although rare, however, ReA could be presented as a complication of Covid-19 vaccination, and physicians should be aware of the possibility of its occurrence.

New-onset Adult-onset Still's disease-like syndrome after ChAdOx1 nCoV-19 vaccination-a case series with review of literature

We report a series of 3 Adult-onset Still’s disease (AOSD)-like presentations in previously healthy females following vaccination with the ChAdOx1 nCoV-19 vaccine, and also compare them with similar cases reported in literature through a PubMed database search. Our first patient had a high spiking bi-quotidian type of fever with myalgia, sore throat, and arthritis with onset 10-day post-vaccination, with laboratory features of hyper inflammation responding to only naproxen. She was off treatment after 2 months. The second patient, with onset 3-week post-vaccination, had a more severe illness, requiring high dose immunosuppression. In our third case, the onset of illness was slightly delayed i.e., 3-month post-vaccination, but she had the most severe disease with macrophage activation syndrome at presentation requiring immunosuppression and biologicals. The underlying mechanism may be linked to the activation of Toll-like receptors (TLR)—TLR-7 and TLR-9—leading to a robust immune response. These 3 cases highlight the immunogenicity of COVID-19 vaccines, with the possibility of occurrence of new-onset systemic hyper-inflammation illness which can happen a few days following the vaccination, sometimes even delayed to months, and can range in severity from mild to even life-threatening. More cases need to be studied to understand the profile and prognosis of these syndromes in the long run.

COVID-19 vaccine and autoimmunity. A new case of autoimmune hepatitis and review of the literature

Autoimmunity following COVID-19 vaccination has been reported. Herein, a 79-year-old man with clinical and immunological features of autoimmune hepatitis type 1 after ChAdOx1 nCoV-19 vaccination is presented. Clinical manifestations rapidly remitted after the instauration of immunomodulatory management. This case, together with a comprehensive review of the literature, illustrates the association between COVID-19 vaccines and the development of autoimmune conditions.

Orbital Cellulitis following COVID-19 Vaccination

A 72-year-old male patient was referred to our outpatient clinic with a painful left eye protrusion accompanied by marked conjunctival chemosis and external ophthalmoplegia being progressed despite topical and oral antibiotic therapy. He developed ocular symptoms 9 days after receiving his second SARS-CoV-2 vaccine (VeroCell). Of note, in previous history, 2 weeks after the first dose of the COVID-19 vaccine, he also developed a life-threatening laryngeal oedema treated at an emergency care unit. MRI of the orbit excluded pansinusitis as possible origin of the orbital cellulitis, and repeated COVID-19 antigen and antibody PCR tests were negative during his hospitalization. On the next day after his admittance, parenteral dexamethasone 250 mg/die treatment was commenced resulting in a quick and complete resolution of the symptoms. Due to the facts regarding this case, such as the temporal coincidence and the lack of respective comorbidity, there might be a causative relationship between the vaccination and the presented orbital cellulitis. To the best of our knowledge, this is the first report on orbital cellulitis as a possible ocular adverse event following COVID-19 vaccination.

New-onset autoimmune phenomena post COVID-19 vaccination

Coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to an unprecedented setback for global economy and health. Vaccination is one of the most effective intervention to substantially reduce severe disease and death due to SARS-CoV-2 infection. Vaccination programs are being rolled out globally, but most of these vaccines have been approved without extensive studies on their side effects and efficacy. Recently, new-onset autoimmune phenomena after COVID-19 vaccination have been reported increasingly (e.g., immune thrombotic thrombocytopenia, autoimmune liver diseases, Guillain-Barré syndrome, IgA nephropathy, rheumatoid arthritis and systemic lupus erythematosus, etc.). Molecular mimicry, the production of particular autoantibodies and the role of certain vaccine adjuvants seem to be substantial contributors to autoimmune phenomena. However, whether the association between COVID-19 vaccine and autoimmune manifestations is coincidental or causal remains to be elucidated. Here, we summarize the emerging evidence about autoimmune manifestations occurring in response to certain COVID-19 vaccines. Although information pertaining to the risk of autoimmune disease as a consequence of vaccination is controversial, we merely propose our current understanding of autoimmune manifestations associated with COVID-19 vaccine. In fact, we do not aim to disavow the overwhelming benefits of mass COVID-19 vaccination in preventing COVID-19 morbidity and mortality. These reports could help guide clinical assessment and management of autoimmune manifestations after COVID-19 vaccination.

COVID-19 from a rheumatology perspective: bibliometric and altmetric analysis

The Coronavirus disease 2019 (COVID-19) outbreak turned out the greatest pandemic for decades. It challenged enormously the global health system, forcing it to adjust to the new realities. We aimed to analyze articles covering COVID-19 papers in the rheumatological field and outline emerging topics raising within this frame. We applied the bibliometric database Scopus for our literature search and conducted it on the 5th of June using the following keywords: "rheumatic" OR "rheumatology" OR "rheumatoid arthritis" OR "systemic lupus erythematosus" OR "myositis" OR "systemic sclerosis" OR "vasculitis" OR "arthritis" OR "ankylosing spondylitis" AND "COVID-19". We analyzed all selected articles according to various aspects: type of document, authorship, journal, citations score, rheumatology field, country of origin, language, and keywords. With the help of the software tool VOSviewer version 1.6.15, we have built the visualizing network of authors and keywords co-occurrence. The measurement of the social impact of articles was made using Altmetric data. This study included 1430 retrieved articles with open access mostly. The top five journals in this field were Annals of the Rheumatic Diseases (n = 65), Rheumatology International (n = 51), Clinical Rheumatology (n = 50), Lancet Rheumatology (n = 50), and Frontiers In Immunology (n = 33). Most studies originate from countries with a high incidence of COVID-19 among the general population (the USA-387; Italy-268; UK-184; France-114; Germany-110; India-98 and Spain-96, China-94, Canada-73 Turkey-66). Original Articles (42.1%) were the most common articles' type, following by Letters (24.4%), Reviews (21.7%), Notes (6%), Editorials (4.8%), Erratum (1%). According to the citations scores, articles dedicated to the clinical course of COVID-19 in patients with rheumatic diseases were of the highest importance for the scientific rheumatologic community. Rheumatoid arthritis (n = 527), systemic lupus erythematosus (n = 393), vasculitis (n = 267), myositis (n = 71), systemic sclerosis (n = 68), and psoriatic arthritis (n = 68) were the most widely discussed rheumatic diseases in the view of COVID-19. The analysis of Altmetric and citations scores revealed a moderate correlation between them. This article provides a comprehensive bibliometric and altmetric analysis of COVID-19 related articles in the rheumatology field and summarizes data about features of rheumatology service in the time of the pandemic.

Counting on COVID-19 Vaccine: Insights into the Current Strategies, Progress and Future Challenges

The emergence of a novel coronavirus viz., severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in late 2019 and its subsequent substantial spread produced the coronavirus disease 2019 (COVID-19) pandemic worldwide. Given its unprecedented infectivity and pathogenicity, the COVID-19 pandemic had a devastating impact on human health, and its clinical management has been a great challenge, which has led to the development and speedy trials of several vaccine candidates against SARS-CoV-2 at an exceptional pace. As a result, several COVID-19 vaccines were made commercially available in the first half of 2021. Although several COVID-19 vaccines showed promising results, crucial insights into their epidemiology, protective mechanisms, and the propensities of reinfection are not largely reviewed. In the present report, we provided insights into the prospects of vaccination against COVID-19 and assessed diverse vaccination strategies including DNA, mRNA, protein subunits, vector-based, live attenuated, and inactivated whole/viral particle-based vaccines. Next, we reviewed major aspects of various available vaccines approved by the World Health Organization and by the local administrations to use against COVID-19. Moreover, we comprehensively assessed the success of these approved vaccines and also their untoward effects, including the possibility of reinfection. We also provided an update on the vaccines that are under development and could be promising candidates in the future. Conclusively, we provided insights into the COVID-19 vaccine epidemiology, their potency, and propensity for SARS-CoV-2 reinfection, while a careful review of their current status, strategies, success, and future challenges was also presented.

Arthritis following COVID-19 vaccination: report of two cases

While most patients with coronavirus disease 2019 (COVID-19) present with mild or moderate symptoms, 15% may develop severe pneumonia, 5% develop acute respiratory distress syndrome (ARDS), septic shock, and multiple organ failure. Some patients may also experience arthralgia or arthritis. Cases of reactive arthritis have been reported during or after COVID-19. With the approval of the use of COVID-19 vaccines, the vaccination program was started in our country and is still continuing.Here we present two patients who developed arthritis after COVID-19 vaccination.

Severe but Self-Limiting Polyarthralgia with Functional Impairment Following ChAdOx1 nCov-19 Vaccination in an Elderly Recipient

A 79-year-old female patient with no pre-existing rheumatological conditions presented with severe functional impairment secondary to polyarthralgia, most likely an adverse reaction following her first dose of Oxford/AstraZeneca ChAdOx1 nCov-19 vaccination against SARS-CoV-2, the causative agent of Coronavirus Disease 2019 (COVID-19). The presentation mimicked clinical features of polymyalgia rheumatica and was distinctive in its pattern and delayed onset. Its severity in an elderly patient was significant against trial findings of decreasing reactogenicity of ChAdOx1 nCov-19 vaccine with increasing age, and traumatic to the patient. Acute phase reactants were elevated, consistent with recent similar reports among mostly elderly, female patients. New onset rheumatological conditions and flares of pre-existing, well-controlled conditions had been well established in COVID-19 and, to a lesser extent, post-vaccination. Viral arthralgias as a distinct clinical entity in COVID-19 is only beginning to be recognized. It could be that this case report represents a similar entity which occurs following vaccination against SARS-CoV-2. Despite this, the benefits of vaccination continue to outweigh such risks, although this case report is important for providing understanding of clinical progression when such reactions occur, aiding in patient discussions and clinical decisions to weigh up further investigations or empirical treatment against reassurance and close monitoring.