Spectrum of short-term inflammatory musculoskeletal manifestations after COVID-19 vaccine administration: a report of 66 cases

Autoimmune disorders reported following COVID-19 vaccination: A disproportionality analysis using the WHO database

PURPOSE

Owing to adverse event following immunization (AEFI) related to autoimmune disorders and coronavirus disease 2019 (COVID-19) vaccines sharing common biological mechanisms, identifying the risk of AEFIs associated with COVID-19 vaccines remains a critical unmet need. We aimed to assess the potential safety signals for 16 AEFIs and explore co-reported adverse events (AEs) and drugs using the global database of the World Health Organization, VigiBase.

METHODS

We assessed the occurrence of 16 AEFIs following COVID-19 vaccination through the Standardized MedDRA Queries group "Immune-mediated/Autoimmune Disorders" from MedDRA and performed a disproportionality analysis using reporting odds ratio (ROR) and information component (IC) with 95% confidence intervals (CIs).

RESULTS

We identified 25,219 events associated with COVID-19 vaccines in VigiBase. Although rare, we detected four potential safety signals related to autoimmune disorders following COVID-19 vaccination, including ankylosing spondylitis or psoriatic arthritis (ROR 1.86; 95% CI 1.53-2.27), inflammatory bowel disease (ROR 1.77; 95% CI 1.60-1.96), polymyalgia rheumatica (ROR 1.42; 95% CI 1.30-1.55), and thyroiditis (ROR 1.40; 95% CI 1.30-1.50), with positive IC025 values. The top co-reported AEs were musculoskeletal disorders, and immunosuppressants were the most representative co-reported drugs.

CONCLUSION

In addressing the imperative to comprehend AEFI related to autoimmune disorders following COVID-19 vaccination, our study identified four potential safety signals. Thus, our research underscores the importance of proactive safety monitoring for the identification of the four AEFIs following COVID-19 vaccination, considering the associated advantages.

Recent advances and evolving concepts in Still's disease

Still's disease is a rare inflammatory syndrome that encompasses systemic juvenile idiopathic arthritis and adult-onset Still's disease, both of which can exhibit life-threatening complications, including macrophage activation syndrome (MAS), a secondary form of haemophagocytic lymphohistiocytosis. Genetic insights into Still's disease involve both HLA and non-HLA susceptibility genes, suggesting the involvement of adaptive immune cell-mediated immunity. At the same time, phenotypic evidence indicates the involvement of autoinflammatory processes. Evidence also implicates the type I interferon signature, mechanistic target of rapamycin complex 1 signalling and ferritin in the pathogenesis of Still's disease and MAS. Pathological entities associated with Still's disease include lung disease that could be associated with biologic DMARDs and with the occurrence of MAS. Historically, monophasic, recurrent and persistent Still's disease courses were recognized. Newer proposals of alternative Still's disease clusters could enable better dissection of clinical heterogeneity on the basis of immune cell profiles that could represent diverse endotypes or phases of disease activity. Therapeutically, data on IL-1 and IL-6 antagonism and Janus kinase inhibition suggest the importance of early administration in Still's disease. Furthermore, there is evidence that patients who develop MAS can be treated with IFNγ antagonism. Despite these developments, unmet needs remain that can form the basis for the design of future studies leading to improvement of disease management.

Intraneural ganglion cyst of the peroneal nerve occurring after coronavirus disease-19 vaccination: A case report

Ganglion cysts are relatively common, but intraneural ganglion cysts (INGCs) within peripheral nerves are rare and poorly understood. We present the case of a 58-year-old woman who presented with acute right-foot drop. She experienced acute knee pain radiating from the lateral leg to the dorsal foot two days after the first coronavirus disease-19 (COVID-19) vaccination (BNT162b2, Pfizer-BioNTech). She had no history of trauma or medication use. Two weeks after the onset of symptoms, she developed a dorsiflexor weakness of the right foot (Medical Research Council grade, poor). The weakness worsened to a "trace" grade despite providing conservative management for one month. Ultrasonography revealed a fusiform echolucent structure within the course of the right common peroneal nerve around the fibular head. Magnetic resonance imaging revealed multiple intraneural cysts within the right common peroneal nerve. Nerve conduction and electromyographic studies revealed multiphasic motor unit action potentials accompanied by abnormal spontaneous activities in the innervated muscles, along with axonal degeneration of the deep peroneal nerves. Surgical removal of the cyst was performed, and the patient's symptoms gradually improved. Pathological examination revealed a cystic structure containing mucinous or gelatinous fluid and lined with flattened or cuboidal cells. The clinical course and sequential electromyographic findings relevant to this symptomatic cyst were temporally related to the vaccination date. The present case suggests that INGC-induced peroneal palsy is a possible complication after COVID-19 vaccination.

Patient Presentations in a Community Pain Clinic after COVID-19 Infection or Vaccination: A Case-Series Approach

OBJECTIVES

Early case report studies and anecdotes from patients, medical colleagues, and social media suggest that patients may present to chronic pain clinics with a number of complaints post COVID-19 infection or vaccination. The aim of this study is to systematically report on a consecutive series of chronic pain patients seen in a community-based pain clinic, who acquired symptoms after COVID-19 infection or vaccination.

METHODS

This retrospective cross-sectional descriptive study identified all patients seen at the clinic over a 4-month period (January-April 2022) with persistent symptoms after COVID-19 infection, vaccination, or both. Information was collected on sex, gender, age, details of vaccination, new pains, or exacerbation of old pain plus the development of novel symptoms.

RESULTS

The study identified 21 community dwellers (17 females and 4 males; F/M 4.25/1; age range 22-79 years; mean age 46.3 years), with symptoms attributed to COVID-19 infection or vaccination. Several patients suffered exacerbation of previous pains or developed novel pains, as well as high levels of anxiety and mood disorders. A review of the existing literature provides support for the spectrum of symptoms displayed by the study group.

CONCLUSIONS

Information collected in this study will add to the body of COVID-19-related literature and assist particularly community practitioners in recognizing and managing these conditions.

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.

Increased Frequency of Low Back Pain in Recent Times: Does the Answer Lie in COVID-19?

Background The COVID-19 pandemic has impacted many people's activities of daily living and health. It has also created economic burdens and caused mental turmoil across the world. Musculoskeletal symptoms, especially low back pain, have been observed in subjects of post-COVID-19 infection and post-vaccination. Aim In this study, we aimed to investigate the relationship between low back pain and COVID-19 infection and vaccination, as well as associated factors and characteristics. Methods We conducted a questionnaire-based cross-sectional observational study at All India Institute of Medical Science (AIIMS) Bibinagar between September 2021 and March 2022. We collected data from individuals through physical and Google Forms (Google, Mountain View, California).  Results We included a total of 535 individuals in the study: 274 (51.2%) were previously positive for COVID-19 infection (group A), and 261 (48.8%) were vaccinated against COVID-19 without a history of COVID-19 infection (group B). Each group was divided into two categories based on whether they had low back pain before COVID-19 infection or vaccination. In group A, 90.1% of individuals experienced an aggravation of low back pain after COVID-19 infection, which was found to be significant (p<0.001). In group B, there was an insignificant increase in low back pain following COVID-19 vaccination (p=0.275). The study also revealed a significant association between comorbidities and low back pain in both groups (p<0.001). Additionally, several differences were observed between the two groups, including duration (p<0.001), severity (p=0.012), and intensity (p<0.001) of low back pain, usage of a back support or brace (p=0.043), and intake of vitamin D (p=0.002).  Conclusion Low back pain is an ignored feature of one of the musculoskeletal symptoms of COVID-19 and was aggravated by COVID-19 infection in our patients compared to those who received the vaccination. The findings of this study have implications for raising awareness, improving management and rehabilitation, and guiding future research in this area.

Wrist Extensor Tenosynovitis After COVID-19 Vaccination

We present the case of a 54-year-old right-handed woman with no medical history of rheumatic disease or trauma to the upper extremities who developed painful nodules along her left upper extremity and torso immediately after receiving the mRNA-1273 SARS-CoV-2 vaccine booster for COVID-19 in her left upper extremity. Most of the nodules subsided within several days, but several persisted over the dorsum of the left wrist with physical examination and imaging findings consistent with second and fourth extensor compartment tenosynovitis. She ultimately underwent excision of the left wrist extensor tenosynovitis, followed by a repeat excision for recurrence of symptoms.

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.

Inflammatory rheumatic diseases with onset after SARS-CoV-2 infection or COVID-19 vaccination: a report of 267 cases from the COVID-19 and ASD group

OBJECTIVES

To better define the spectrum of new-onset post-COVID-19 and post-COVID-19 vaccine inflammatory rheumatic diseases (IRD) from a large multicentric observational study.

METHODS

Consecutive cases of IRD encountered during a 12-month period and satisfying one of the following inclusion criteria: (a) onset of the rheumatic manifestations within 4 weeks from SARS-CoV-2 infection or (b) onset of the rheumatic manifestations within 4 weeks from the administration of one of the COVID-19 vaccines ws recruited.

RESULTS

The final analysis cohort comprised 267 patients, of which 122 (45.2%) in the post-COVID-19 and 145 (54.8%) in the postvaccine cohort. Distribution of IRD categories differed between the two cohorts: the post-COVID-19 cohort had a higher percentage of patients classified as having inflammatory joint diseases (IJD, 52.5% vs 37.2%, p=0.013) while the post-vaccine cohort had a higher prevalence of patients classified as polymyalgia rheumatica (PMR, 33.1% vs 21.3%, p=0.032). No differences were detected in the percentage of patients diagnosed with connective tissue diseases (CTD 19.7% vs 20.7%, p=0.837) or vasculitis (6.6% vs 9.0%, p=0.467). Despite the short follow-up period, IJD and PMR patients' response to first-line therapy was favourable, with both groups achieving a drop in baseline disease activity scores of ~30% and ~70% respectively.

CONCLUSION

Our article reports the largest cohort published to date of new-onset IRD following SARS-CoV-2 infection or COVID-19 vaccines. Although causality cannot be ascertained, the spectrum of possible clinical manifestations is broad and includes IJD, PMR, CTD and vasculitis.

Post-Acute COVID-19 Joint Pain and New Onset of Rheumatic Musculoskeletal Diseases: A Systematic Review

As the number of reports of post-acute COVID-19 musculoskeletal manifestations is rapidly rising, it is important to summarize the current available literature in order to shed light on this new and not fully understood phenomenon. Therefore, we conducted a systematic review to provide an updated picture of post-acute COVID-19 musculoskeletal manifestations of potential rheumatological interest, with a particular focus on joint pain, new onset of rheumatic musculoskeletal diseases and presence of autoantibodies related to inflammatory arthritis such as rheumatoid factor and anti-citrullinated protein antibodies. We included 54 original papers in our systematic review. The prevalence of arthralgia was found to range from 2% to 65% within a time frame varying from 4 weeks to 12 months after acute SARS-CoV-2 infection. Inflammatory arthritis was also reported with various clinical phenotypes such as symmetrical polyarthritis with RA-like pattern similar to other prototypical viral arthritis, polymyalgia-like symptoms, or acute monoarthritis and oligoarthritis of large joints resembling reactive arthritis. Moreover, high figures of post-COVID-19 patients fulfilling the classification criteria for fibromyalgia were found, ranging from 31% to 40%. Finally, the available literature about prevalence of rheumatoid factor and anti-citrullinated protein antibodies was largely inconsistent. In conclusion, manifestations of rheumatological interest such as joint pain, new-onset inflammatory arthritis and fibromyalgia are frequently reported after COVID-19, highlighting the potential role of SARS-CoV-2 as a trigger for the development of autoimmune conditions and rheumatic musculoskeletal diseases.

Long-Term Safety Analysis of the ChAdOx1-nCoV-19 Corona Virus Vaccine: Results from a Prospective Observational Study in Priority Vaccinated Groups in North India

INTRODUCTION

Various vaccines for protection against COVID-19 were provided emergency approval in late 2020 to early 2021. There is a scarcity of long-term safety data for many of these.

OBJECTIVE

The main aim of this study is to provide the one-year safety results of the ChAdOx1-nCoV-19/AZD1222 vaccine and determine the risk factors of adverse events of special interest (AESIs) and persistent AESIs.

METHODS

This was a prospective observational study conducted from February 2021 to April 2022 in a tertiary hospital in North India and its two associated centers. Health care workers, other frontline workers, and the elderly vaccinated with the ChAdOx1-nCoV-19 vaccine constituted the study population. Individuals were contacted telephonically at pre-decided intervals for one year and health issues of significant concern were recorded. Atypical adverse events developing after a booster dose of the COVID-19 vaccine were assessed. Regression analysis was conducted to determine risk factors of AESI occurrence and determinants of AESIs persisting for at least one month at the time of final telephonic contact.

RESULTS

Of 1650 individuals enrolled, 1520 could be assessed at one-year post-vaccination. COVID-19 occurred in 44.1% of participants. Dengue occurred in 8% of participants. The majority of the AESIs belonged to the MedDRA^® SOC of musculoskeletal disorders (3.7% of 1520). Arthropathy (knee joint involvement) was the most common individual AESI (1.7%). Endocrinal disorders such as thyroid abnormalities and metabolic disorders such as newly diagnosed diabetes developed in 0.4% and 0.3% of individuals, respectively. Regression analysis showed females, individuals with a pre-vaccination history of COVID-19, diabetes, hypothyroidism, and arthropathy had 1.78-, 1.55-, 1.82-, 2.47- and 3.9-times higher odds of AESI development. Females and individuals with hypothyroidism were at 1.66- and 2.23-times higher risk of persistent AESIs. Individuals receiving the vaccine after COVID-19 were at 2.85- and 1.94 times higher risk of persistent AESIs compared, respectively, to individuals with no history of COVID-19 and individuals developing COVID-19 after the vaccine. Among participants receiving a booster dose of the COVID-19 vaccine (n = 185), 9.7% developed atypical adverse events of which urticaria and new-onset arthropathy were common.

CONCLUSION

Nearly half of the ChAdOx1-nCoV-19 vaccine recipients developed COVID-19 over one year. Vigilance is warranted for AESIs such as musculoskeletal disorders. Females, individuals with hypothyroidism, diabetes, and pre-vaccination history of COVID-19 are at higher risk of adverse events. Vaccines received after natural SARS-CoV-2 infection may increase the risk of persistence of adverse events. Sex and endocrinal differences and timing of the COVID-19 vaccine with respect to natural infection should be explored as determinants of AESIs in the future. Pathogenetic mechanisms of vaccine-related adverse events should be investigated along with comparisons with an unvaccinated arm to delineate the overall safety profile of COVID-19 vaccines.

New Onset of Giant Cell Arteritis following ChAdOx1-S (Vaxevria®) Vaccine Administration

We report a 78-year-old man presenting with persistent headaches in vertex and temporo-parietal area; fatigue, worsening after walking; jaw claudication; scotomas; pharyngodynia; and dry cough after the second dose of the SARS-CoV-2 vaccine (ChAdOx1-S) administration. Laboratory findings showed an elevated C-reactive protein level and FDG-CT PET showed evidence of active large vessel vasculitis with diffuse abnormal artery uptake. Under suspicion of vasculitis, a temporal arteries biopsy was performed; the histopathologic findings demonstrated the transmural inflammatory infiltrate with giant cells, compatible with giant cell arteritis. Although the overall incidence of vaccine-triggered autoimmunity is low, rheumatologists worldwide should be aware of autoimmune diseases as a new potential adverse event of vaccines.

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.

Relapses of idiopathic inflammatory myopathies after vaccination against COVID-19: a real-life multicenter Italian study

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) vaccination plays a crucial role as pivotal strategy to curb the coronavirus disease-19 (COVID-19) pandemic. The present study described the clinical status of patients affected by idiopathic inflammatory myopathies (IIM) after COVID-19 vaccination to assess the number of relapses. We included all patients affected by IIM and followed by Myositis Clinic, Rheumatology and Respiratory Diseases Units, Siena University Hospital, Bari University Hospital, Policlinico Umberto I, Sapienza University, Rome, and Policlinico Paolo Giaccone, Palermo. They underwent a telephone survey. A total of 119 IIM patients (median, IQR 58 (47-66) years; 32males; 50 dermatomyositis, 39 polymyositis and 30 anti-synthetase syndrome) were consecutively enrolled. Except four patients who refused the vaccination, 94 (81.7%) received Comirnaty, 16 (13.9%) Spikevax, 5 (4.4%) Vaxzevria. Seven (6.1%) patients had flare after vaccination. One of them had life-threatening systemic involvement and died two months after second dose of COVID-19 vaccination. From logistic regression analysis, Chi²-log ratio = 0.045,the variable that most influences the development of flare was the number of organs involved (p = 0.047). Sixty-eight patients received the third dose of COVID-19 vaccination: 51(75%) Comirnaty and 17 (25%) Moderna. No patients had flares after third dose. Our study represents the largest cohort of IIM patients in which the incidence of recurrence after anti-SARS-CoV-2 vaccine was assessed. In line with real-life data from other diseases, we found a clinical non-statistically significant risk of relapse in our patients, which occurred seldom, usually mild and in patients with a more severe and aggressive course of disease.

Immune-mediated inflammatory diseases after anti-SARS-CoV-2 vaccines: new diagnoses and disease flares

Objective

New-onset immune-mediated inflammatory diseases (IMIDs) and flares of pre-existing IMIDs have been reported following anti- SARS-CoV2 vaccination. Our study aimed at describing a retrospective cohort of patients developing new-onset IMIDs or flares of known IMIDs within 30 days after any anti-SARS-CoV2 vaccine dose.

Methods

We evaluated clinical records of all inpatients and outpatients referring to our institution between February 2021 and February 2022 with any clinical manifestations. We then selected those having received any anti-SARS-CoV2 vaccine dose within the prior 30 days and classified them as having or not a previous IMID according to predefined criteria. We recorded new-onset IMIDs or flares of known IMIDs and investigated any relationship with demographic, clinical and serological variables.

Results

153 patients that received any anti-SARS-CoV2 vaccine dose within the previous 30 days were included of which 45 (29%) already had a diagnosis of IMID while 108 (71%) had no previously diagnosed IMID. 33 (30%) of the 108 patients, were diagnosed with a new-onset IMID. Pericarditis, polymyalgia rheumatica and vasculitis were the most frequent conditions. Among the 45 patients that already had an IMID, disease flare was the reason for referral in 69% of patients. Patients with an IMID flare had a lower number of comorbidities and tended to be younger compared with those who developed other conditions after anti-SARS-CoV2 vaccination.

Conclusion

We provided a retrospective overview of a cohort of patients who developed new-onset IMIDs or flares of known IMIDs within 30 days after any dose of anti-SARS-CoV2 vaccine. While vaccination campaigns proceed, postvaccination surveillance programmes are ongoing and hopefully will soon clarify whether a causal relationship between vaccines and new-onset/flares of IMIDs exists.

Musculoskeletal Manifestations of COVID-19: Currently Described Clinical Symptoms and Multimodality Imaging Findings

COVID-19, the clinical syndrome produced by infection with SARS-CoV-2, can result in multisystem organ dysfunction, including respiratory failure and hypercoagulability, which can lead to critical illness and death. Musculoskeletal (MSK) manifestations of COVID-19 are common but have been relatively underreported, possibly because of the severity of manifestations in other organ systems. Additionally, patients who have undergone sedation and who are critically ill are often unable to alert clinicians of their MSK symptoms. Furthermore, some therapeutic measures such as medications and vaccinations can worsen existing MSK symptoms or cause additional symptoms. Symptoms may persist or occur months after the initial infection, known as post-COVID condition or long COVID. As the global experience with COVID-19 and the vaccination effort increases, certain patterns of MSK disease involving the bones, muscles, peripheral nerves, blood vessels, and joints have emerged, many of which are likely related to a hyperinflammatory host response, prothrombotic state, or therapeutic efforts rather than direct viral toxicity. Imaging findings for various COVID-19–related MSK pathologic conditions across a variety of modalities are being recognized, which can be helpful for diagnosis, treatment guidance, and follow-up.

The online slide presentation from the RSNA Annual Meeting is available for this article.

^©RSNA, 2022

Rheumatoid arthritis and post-COVID-19 syndrome

In the third year of the SARS-CoV-2 (severe acute respiratory syndrome coronavirus-2, COVID-19) pandemic doctors are encountering a new pathology – post-COVID-19 syndrome (PCS, long covid). Musculoskeletal manifestations are among the most common and may present as myalgia, arthralgia, or arthritis. Currently, there is no generally accepted definition of the disease, its duration, classification, or diagnostic criteria, and no single view on the “content” of musculoskeletal manifestations of PCS. We have enough descriptions of the debut of rheumatoid arthritis (RA) after SARS-CoV-2. That is a question: it is a coincidence, or COVID-19 may be a trigger factor of RA? We thought that SARS-CoV-2 infection may be a trigger factor for new rheumatic musculoskeletal diseases, including rheumatoid arthritis or COVID-19 can unmask previously undetected RA. The occurrence of arthritis may be a sign of PCS with transient character. So arthritis in the post covid period may induce problems in differential diagnosis of rheumatic diseases. 

Polymyalgia Rheumatica Following COVID-19 Vaccination

We herein report a 71-year-old woman presented with a fever, arthralgia, general malaise and leg muscle stiffness following administration of the COVID-19 mRNA vaccine (Comirnaty, Pfizer-BioNTech). Laboratory findings showed an elevated C-reactive protein level and erythrocyte sedimentation rate. In addition, Gallium-67 scintigraphy demonstrated an increased uptake in multiple joints. Typing of human leukocyte antigen (HLA) revealed the presence of the DRB1*0404/*0803 allele. These findings met the diagnostic criteria for polymyalgia rheumatica (PMR), and when we started steroid treatment, her symptoms improved rapidly. This patient developed PMR after receiving a COVID-19 mRNA vaccine (Comirnaty, Pfizer-BioNTech). This case is considered to be valuable, as the HLA-DRB1 allele was also confirmed.

Autoimmune post-COVID vaccine syndromes: does the spectrum of autoimmune/inflammatory syndrome expand?

To date, around 60% of the world population has been protected by vaccines against SARS-CoV-2, significantly reducing the devastating effect of the pandemic and restoring social economic activity through mass vaccination. Multiple studies have demonstrated the effectiveness and safety of vaccines against COVID-19 in healthy populations, in people with risk factors, in people with or without SARS-CoV-2 infection, and in immunocompromised people. According to the criteria for post-vaccine adverse events established by the World Health Organization, a minority of individuals may develop adverse events, including autoimmune syndromes. The exact mechanisms for the development of these autoimmune syndromes are under study, and to date, a cause-effect relationship has not been established. Many of these autoimmune syndromes meet sufficient criteria for the diagnosis of Adjuvant-Induced Autoimmune Syndrome (ASIA syndrome). The descriptions of these autoimmune syndromes open new perspectives to the knowledge of the complex relationship between the host, its immune system, with the new vaccines and the development of new-onset autoimmune syndromes. Fortunately, most of these autoimmune syndromes are easily controlled with steroids and other immunomodulatory medications and are short-lived. Rheumatologists must be alert to the development of these autoimmune syndromes, and investigate the relationship between autoimmune/inflammatory symptoms and vaccination time, and assess their therapeutic response.

Rheumatologists’ knowledge and perception of COVID-19 and related vaccines: the vaXurvey2 online survey

The study aimed to explore the experience of coronavirus disease-2019 (COVID-19) infection and vaccine adverse events (AEs) among rheumatologists. A validated questionnaire was distributed as a Google form to rheumatologists across the country via social networking sites from late December 2021 till early January 2022. The questionnaire included questions regarding participants' socio-demographic details, COVID-19 infection and vaccination details with special emphasis on AEs. Out of 246 responses, 228 were valid. 200 (81.3%) responders had received the vaccine. The mean age of the 228 participants was 37.9 ± 8.5 years, 196 were females and 32 males (F:M 6.1:1) from 18 governorates across the country. Comorbidities were present in 54 subjects (27%). There was a history of highly suspicious or confirmed COVID-19 infection in 66.7% that were all managed at home. The COVID-19 vaccine was received by 200 and a booster dose of 18.5%. Obesity and musculoskeletal involvement co-morbidities were present only in those with AEs (9.1% and 5.5% respectively). AEs were present in 82%; 66.7% had injection-site tenderness, 50% fatigue, 35.5% fever, 15% chills, 42.5% myalgia, 14.5% arthralgia, 8% low back pain, headache 31%, dizziness 10%, sleepliness 16% and 15% developed post-vaccine. There were no differences according to the geolocation regarding the occurrence of COVID-19 infection (p = 0.19) or AEs post-vaccine (p = 0.58). The adverse events were mostly mild to moderate and tolerable which makes this work in agreement with other studies that support the broad safety of the vaccine in favor of the global benefit from mass vaccination.

Post-acute Sequelae in COVID-19 Survivors: an Overview

In the acute phase of SARS-CoV-2 infection, varying degrees of clinical manifestations have been noticed in patients. Some patients who recovered from the infection developed long-term effects which have become of interest to the scientific and medical communities, as it relates to pathogenesis and the multidisciplinary approach to treatment. Long COVID (long-term or long-haul) is the collective term used to define recovered individuals of SARS-CoV-2 infection who have presented with persistent COVID symptoms, as well as the emergence of disorders and complications. Following the review of literature from major scientific databases, this paper investigated long COVID and the resulting post-sequela effects on survivors, regardless of initial disease severity. The clinical manifestations and multisystem complications of the disease specifically, cardiovascular, neurologic and psychologic, hematologic, pulmonary, dermatologic, and other ailments were discussed. Patients with chronic COVID-19 were found to experience heart thrombosis leading to myocardial infarction, inflammation, lung fibrosis, stroke, venous thromboembolism, arterial thromboembolism, "brain fog", general mood dysfunctions, dermatological issues, and fatigue. As the disease continues to progress and spread, and with the emergence of new variants the management of these persisting symptoms will pose a challenge for healthcare providers and medical systems in the next period of the pandemic. However, more information is needed about long COVID, particularly concerning certain patient populations, variability in follow-up times, the prevalence of comorbidities, and the evolution of the spread of infection. Thus, continued research needs to be conducted concerning the disease pathology to develop preventative measures and management strategies to treat long COVID.

Autoimmune post-COVID vaccine syndromes: does the spectrum of autoimmune/inflammatory syndrome expand?

To date, around 60% of the world population has been protected by vaccines against SARS-CoV-2, significantly reducing the devastating effect of the pandemic and restoring social economic activity through mass vaccination. Multiple studies have demonstrated the effectiveness and safety of vaccines against COVID-19 in healthy populations, in people with risk factors, in people with or without SARS-CoV-2 infection, and in immunocompromised people. According to the criteria for post-vaccine adverse events established by the World Health Organization, a minority of individuals may develop adverse events, including autoimmune syndromes. The exact mechanisms for the development of these autoimmune syndromes are under study, and to date, a cause-effect relationship has not been established. Many of these autoimmune syndromes meet sufficient criteria for the diagnosis of Adjuvant-Induced Autoimmune Syndrome (ASIA syndrome). The descriptions of these autoimmune syndromes open new perspectives to the knowledge of the complex relationship between the host, its immune system, with the new vaccines and the development of new-onset autoimmune syndromes. Fortunately, most of these autoimmune syndromes are easily controlled with steroids and other immunomodulatory medications and are short-lived. Rheumatologists must be alert to the development of these autoimmune syndromes, and investigate the relationship between autoimmune/inflammatory symptoms and vaccination time, and assess their therapeutic response.

SARS-COV-2 Infection, Vaccination, and Immune-Mediated Diseases: Results of a Single-Center Retrospective Study

Objectives

The relationship between infections or vaccine antigens and exacerbations or new onset of immune-mediated diseases (IMDs) has long been known. In this observational study, conducted during the COVID-19 pandemic, we evaluated the onset of clinical and laboratory immune manifestations related to COVID-19 or SARS-CoV-2 vaccination.

Methods

Four groups of patients were evaluated: A) 584 COVID-19 inpatients hospitalized from March 2020 to June 2020 and from November 2020 to May 2021; B) 135 outpatients with previous SARS-CoV-2 infection, assessed within 6 months of recovery; C) outpatients with IMDs in remission and flared after SARS-COV-2 infection; D) outpatients with symptoms of probable immune-mediated origin after SARS-CoV-2 vaccination.

Results

In cohort A we observed n. 28 (4.8%) arthralgia/myalgia, n. 2 (0.3%) arthritis, n. 3 (0.5%) pericarditis, n. 1 (0.2%) myocarditis, n. 11 (1.9%) thrombocytopenia or pancytopenia, and in the follow up cohort B we identified 9 (6.7%) cases of newly diagnosed IMDs after the recovery from COVID-19. In all cases, serological alterations were not observed.In cohort C we observed n.5 flares of pre-existing IMD after SARS-COV2 infection, and in the cohort D n. 13 IMD temporally close with SARS-CoV-2 vaccination in 8 healthy subjects (with clinical classifiable IMD-like presentation) and in 5 patients affected by an anamnestic IMD. Also in these latter cases, except in 2 healthy subjects, there were not found serological alterations specific of a classifiable IMD.

Conclusions

This study suggests that the interplay between SARS-CoV-2 and the host may induce complex immune-mediated reactions, probably induced by the anti-spike antibodies, in healthy people and IMD patients without specific serological autoimmunity. Moreover, our data suggest that the anti-SARS-CoV-2 antibodies generated by the vaccination may cause in healthy subjects' clinical manifestations similar to well-definite IMDs. These findings support the hypothesis that SARS-Cov2 infection in COVID-19 induce an innate and adaptive immune response that may be both responsible of the symptoms correlated with the occurrence of the IMDs described in our study. And, in this context, the IMDs observed in healthy people in close temporal correlation with the vaccination suggest that the anti-Spike antibodies may play a key role in the induction of an abnormal and deregulated immune response.