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Arya Pv A, Madathanapalli KA, Tenezaca FC, Wang A. Temporal arteritis presenting as third nerve palsy - a case report and review of literature. Rheumatol Int 2024; 44:2245-2251. [PMID: 38739224 DOI: 10.1007/s00296-024-05604-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 04/23/2024] [Indexed: 05/14/2024]
Abstract
Giant Cell Arteritis (GCA), also known as Temporal Arteritis, is a type of large vessel vasculitis primarily affecting the elderly population. It typically manifests with headaches, visual impairment, and jaw claudication. Although third nerve palsy as the primary presentation of GCA is rare, it has been reported in previous instances. In this report, we describe the case of a patient presenting with pupil-sparing third nerve palsy, ultimately diagnosed with GCA, and successfully managed with steroids and tocilizumab. A lady in her 80s with past medical history of well-controlled hypertension, bladder cancer in remission, a twenty-pack year smoking history, cervical and lumbar spine stenosis, and recent immunizations presented with acute onset of right-sided pupil-sparing third nerve palsy. Labs were pertinent for an elevated ESR and CRP. Brain imaging was without acute abnormalities. A temporal artery biopsy established evidence of healed arteritis and a diagnosis of GCA was made. The patient was treated with pulse-dose steroids followed by an oral steroid taper and tocilizumab. At one month follow-up, there was partial resolution in her ophthalmoplegia. We underscore the importance of considering temporal arteritis as a potential cause of third nerve palsy in the elderly before attributing it solely to microvascular ischemia, particularly in patients with constitutional features. Additionally, in our comprehensive literature review, we aim to consolidate the existing data from similar presentations, shedding light on the clinical manifestation and disease trajectory.
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Affiliation(s)
- Akhila Arya Pv
- Yale New Haven Health/Bridgeport Hospital, 267 Grant St, Bridgeport, CT, 06610, USA.
| | | | | | - Andrew Wang
- Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA
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2
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Seida I, Alrais M, Seida R, Alwani A, Kiyak Z, Elsalti A, Nil Esirgun S, Abali T, Mahroum N. Autoimmune/inflammatory syndrome induced by adjuvants (ASIA): past, present, and future implications. Clin Exp Immunol 2023; 213:87-101. [PMID: 36881788 PMCID: PMC10324553 DOI: 10.1093/cei/uxad033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 02/06/2023] [Accepted: 03/06/2023] [Indexed: 03/09/2023] Open
Abstract
Adjuvants, as the name indicates, are adjoined material aimed to assist in functioning as when added to vaccines they are meant to boost the effect and strongly stimulate the immune system. The response of the immune system can be unpredictable, and the autoimmune/inflammatory syndrome induced by adjuvants (ASIA) was developed to address possible adverse reactions of an autoimmune and inflammatory type that may be caused by adjuvants. While ASIA, as a syndrome, was coined and defined in 2011; reports describing patients with vague and nonspecific clinical symptoms following vaccinations appeared much earlier. In other words, ASIA came to define, arrange, and unite the variety of symptoms, related to autoimmunity, caused not by the vaccine itself, rather by the adjuvant part of the vaccine such as aluminum, among others. Accordingly, the introduction of ASIA enabled better understanding, proper diagnosis, and early treatment of the disorder. Furthermore, ASIA was shown to be associated with almost all body systems and various rheumatic and autoimmune diseases such as systemic lupus erythematosus, antiphospholipid syndrome, and systemic sclerosis. In addition, the correlation between COVID-19 and ASIA was noticed during the pandemic. In this review, we summarized the reported effects of adjuvants and medical literature before and after ASIA was defined, the several ways ASIA can manifest and impact different systems of the body, and the incidences of ASIA during the COVID-19 pandemic. It is important to clarify, that vaccines are among, if not the, most effective means of fighting infectious diseases however, we believe that vaccines manufacturing is not above criticism, particularly when it comes to added substances possessing a risk of side effects.
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Affiliation(s)
- Isa Seida
- International School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Mahmoud Alrais
- International School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Ravend Seida
- International School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Abdulkarim Alwani
- International School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Zeynep Kiyak
- International School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Abdulrahman Elsalti
- International School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Sevval Nil Esirgun
- International School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Tunahan Abali
- International School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Naim Mahroum
- International School of Medicine, Istanbul Medipol University, Istanbul, Turkey
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3
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Furr T, Garg M. Rare Cases of Polymyalgia Rheumatica After Receiving COVID-19 Vaccinations. Cureus 2023; 15:e37782. [PMID: 37091488 PMCID: PMC10115741 DOI: 10.7759/cureus.37782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2023] [Indexed: 04/25/2023] Open
Abstract
Polymyalgia rheumatica (PMR) is a systemic rheumatic inflammatory disease of adults presenting with symmetrical proximal muscle stiffness and pain predominantly involving the shoulders, neck, and pelvic girdle. The coronavirus disease of 2019 (COVID-19) presented as a pandemic causing worldwide morbidity and mortality in large numbers. Rapid scientific research expedited preventative vaccine development and has helped tremendously in cutting down severe illness, hospitalizations, and death from COVID-19, with the messenger ribonucleic acid (mRNA) vaccines outperforming the others. We present two cases that showcase the incidence of polymyalgia rheumatica after receiving COVID-19 vaccination. Patient 1 is a 69-year-old female who developed arm and thigh stiffness a week before the second dose while receiving her primary Moderna vaccine series. She had an elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), so she was started on low-dose steroids, which were weaned down over a five-month period. Three weeks after receiving her Moderna booster, she had a recurrence of the classic polymyalgia rheumatica symptoms and elevated ESR. She responded to prednisone 15 mg with a successful taper over eight months. Patient 2 is a 74-year-old male who received his primary series and booster through Pfizer-BioNTech. Prior to the booster, he was treated for COVID-19 with monoclonal antibody therapy. He presented to the office with hip and shoulder pain and stiffness along with an elevated C-reactive protein. Consequently, he received 20 mg of prednisone but needed to increase his dose to 25 mg total to help with the control of his inflammation. The goal of this article is to prompt physicians about the possibility of PMR incidence after patients receive vaccinations for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). PMR can be debilitating to the quality of life of patients. Knowing this association allows for more timely and competent treatment. PMR following SARS-CoV-2 vaccinations is continuously being observed in the medical field. Increased knowledge may help prevent the recurrence with subsequent doses. Further studies on the follow-up of such cases and the effect on subsequent immunization would be helpful.
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Affiliation(s)
- Todd Furr
- Internal Medicine, Ascension Providence Hospital, Southfield, USA
| | - Manisha Garg
- Internal Medicine, Ascension Providence Hospital, Southfield, USA
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4
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Vaccines and Autoimmunity-From Side Effects to ASIA Syndrome. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020364. [PMID: 36837564 PMCID: PMC9966463 DOI: 10.3390/medicina59020364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/20/2022] [Accepted: 01/05/2023] [Indexed: 02/17/2023]
Abstract
Since vaccines are in fact manufactured chemical compounds such as drugs, the appearance of side effects following their use is not surprising. Similarly, as the main goal of vaccines is to stimulate the immune system bringing out the production of protective antibodies, autoimmune-related side effects as a consequence of increased immune activity do not seem irrational. Fortunately, the rate of such side effects is low; however, the importance of reporting adverse events following vaccinations, understanding the mechanisms behind their appearance, making early diagnosis, and appropriate treatment cannot be overemphasized. In fact, autoimmune-related side effects of vaccines, particularly those based on adjuvants, were reported long before the introduction of the autoimmune/inflammatory syndrome induced by adjuvants (ASIA). Nevertheless, ASIA gathered and united the side effects of vaccines under one title, a step which helped organize the research and call for better immune stimulators than adjuvants. New technologies and methods of making vaccines were clearly noticed during the pandemic of COVID-19 after the introduction of mRNA-based vaccines. In our current paper, we introduce the notion of side effects to vaccines, particularly those of autoimmune nature, the mechanisms of ASIA, and the main vaccines linked with the syndrome including the recent COVID-19 vaccines. The transition from side effects to ASIA is the main idea behind our work.
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5
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Kim Y, Kang J, Lee SG, Kim GT. COVID-19 vaccination-related small vessel vasculitis with multiorgan involvement. Z Rheumatol 2022; 81:509-512. [PMID: 35587834 PMCID: PMC9118190 DOI: 10.1007/s00393-022-01159-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/25/2021] [Indexed: 12/18/2022]
Abstract
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).
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Affiliation(s)
- Yunkyung Kim
- Division of Rheumatology, Department of Internal Medicine, Kosin University College of Medicine, 262, Gamcheon-ro, Seo-gu, 49267, Busan, Korea (Republic of)
| | - Jihun Kang
- Department of Family Medicine, Kosin University Gospel Hospital, Kosin University College of Medicine, 262, Gamcheon-ro, Seo-gu, 49267, Busan, Korea (Republic of).
| | - Seung-Geun Lee
- Division of Rheumatology, Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea (Republic of)
| | - Geun-Tae Kim
- Division of Rheumatology, Department of Internal Medicine, Kosin University College of Medicine, 262, Gamcheon-ro, Seo-gu, 49267, Busan, Korea (Republic of).
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Autoimmune post-COVID vaccine syndromes: does the spectrum of autoimmune/inflammatory syndrome expand? Clin Rheumatol 2022. [PMID: 35378658 DOI: 10.1007/s10067-022-06149-4/tables/1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
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.
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7
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Autoimmune post-COVID vaccine syndromes: does the spectrum of autoimmune/inflammatory syndrome expand? Clin Rheumatol 2022; 41:1603-1609. [PMID: 35378658 PMCID: PMC8979721 DOI: 10.1007/s10067-022-06149-4] [Citation(s) in RCA: 76] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 03/16/2022] [Accepted: 03/23/2022] [Indexed: 12/14/2022]
Abstract
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.
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8
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Greb CS, Aouhab Z, Sisbarro D, Panah E. A Case of Giant Cell Arteritis Presenting After COVID-19 Vaccination: Is It Just a Coincidence? Cureus 2022; 14:e21608. [PMID: 35228965 PMCID: PMC8873313 DOI: 10.7759/cureus.21608] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2022] [Indexed: 02/06/2023] Open
Abstract
Giant cell arteritis (GCA) is a large vessel vasculitis with variable presentations, including fevers, myalgias, headache, and jaw claudication. A particularly concerning symptom is transient vision loss, which may become irreversible without prompt recognition and treatment. The pathogenesis of GCA is incompletely understood, but it seems that the innate and adaptive immune systems play a key role in vessel inflammation, remodeling, and occlusion. We present a case of a 79-year-old male who developed GCA two days after he received his second dose of a COVID-19 mRNA vaccine. He presented with headaches, fever, and myalgias. Lab workup revealed elevated inflammatory markers, with C-reactive protein (CRP) 272 mg/L (<8.1 mg/L) and erythrocyte sedimentation rate (ESR) 97 mm/hr (0-20mm/hr). Imaging of the head, with CT and MRI, was unremarkable. His headache persisted despite supportive treatment, and he developed new, transient blurred vision, which increased suspicion for GCA. He underwent bilateral temporal artery biopsies, which were consistent with GCA. His symptoms resolved quickly with oral prednisone 60mg daily, and his inflammatory markers returned to normal within a month. A review of the literature revealed several case reports of giant cell arteritis following influenza vaccination. However, no large-scale studies have demonstrated a causal relationship between GCA and immunization. Our case demonstrates the first instance of GCA following a COVID-19 mRNA vaccine. We propose that the upregulated immune response to the vaccine acted as a trigger for GCA in this patient with predisposing factors. While causation cannot be determined based on one case alone, our case demonstrates an opportunity for further research into the relationship between vasculitis and immunizations. Despite this isolated case, the proven benefits of COVID-19 mRNA vaccines significantly outweigh any theoretical risk of immune dysregulation following administration.
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Affiliation(s)
| | - Zineb Aouhab
- Rheumatology, Loyola University Medical Center, Maywood, USA
| | - Daniel Sisbarro
- Internal Medicine, Loyola University Medical Center, Maywood, USA
| | - Elnaz Panah
- Pathology, Loyola University Medical Center, Maywood, USA
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9
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Maleki A, Look-Why S, Manhapra A, Foster CS. COVID-19 Recombinant mRNA Vaccines and Serious Ocular Inflammatory Side Effects: Real or Coincidence? J Ophthalmic Vis Res 2021; 16:490-501. [PMID: 34394876 PMCID: PMC8358769 DOI: 10.18502/jovr.v16i3.9443] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 04/28/2021] [Indexed: 12/29/2022] Open
Abstract
Purpose To report two cases; bilateral arteritic anterior ischemic optic neuropathy (AAION) and bilateral acute zonal occult outer retinopathy (AZOOR) after COVID-19 mRNA vaccination. Case Report The first patient was a 79-year-old female was presented to us 35 days after a sudden bilateral loss of vision, which occurred two days after receiving the second recombinant mRNA vaccine (Pfizer) injection. Temporal artery biopsy was compatible with AAION. At presentation, the best-corrected visual acuity was 20/1250 and 20/40 in the right and left eyes on the Snellen acuity chart, respectively. There was 3+ afferent pupillary defect in the right eye. The anterior segment and posterior segment exams were normal except for pallor of the optic nerve head in both eyes. Intraocular pressure was normal in both eyes. She was diagnosed with bilateral AAION and Subcutaneous tocilizumab 162 mg weekly was recommended with monitoring her ESR, CRP, and IL-6. The second patient was a 33-year-old healthy female who was referred to us for a progressive nasal field defect in her left eye, and for flashes in both eyes. Her symptoms started 10 days after receiving the second recombinant mRNA vaccine (Moderna) injection. Complete bloodwork performed by a uveitis specialist demonstrated high ESR (25) and CRP (19) levels. As a result, she was diagnosed with unilateral AZOOR in her left eye and was subsequently treated with an intravitreal dexamethasone implant in the same eye. At presentation, vision was20/20 in both eyes. The anterior segment and posterior segment exams were completely normal except for the presence of abnormal white reflex in the temporal macula of her left eye. We diagnosed her with bilateral AZOOR. Since she was nursing, intravitreal dexamethasone implant was recommended for the right eye. Conclusion There may be a correlation between ocular inflammatory diseases with autoimmune mechanism and the mRNA COVID-19 vaccination.
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Affiliation(s)
- Arash Maleki
- Massachusetts Eye Research and Surgery Institution, Waltham, MA, United States.,The Ocular Immunology and Uveitis Foundation, Waltham, MA, United States
| | - Sydney Look-Why
- Massachusetts Eye Research and Surgery Institution, Waltham, MA, United States.,The Ocular Immunology and Uveitis Foundation, Waltham, MA, United States
| | - Ambika Manhapra
- Massachusetts Eye Research and Surgery Institution, Waltham, MA, United States.,The Ocular Immunology and Uveitis Foundation, Waltham, MA, United States
| | - C Stephen Foster
- The Ocular Immunology and Uveitis Foundation, Waltham, MA, United States.,Harvard Medical School, Department of Ophthalmology, Boston, MA, United States
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Olivieri B, Betterle C, Zanoni G. Vaccinations and Autoimmune Diseases. Vaccines (Basel) 2021; 9:vaccines9080815. [PMID: 34451940 PMCID: PMC8402446 DOI: 10.3390/vaccines9080815] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/12/2021] [Accepted: 07/15/2021] [Indexed: 12/12/2022] Open
Abstract
Vaccines represent one of the most effective measures of public health medicine, saving countless lives and preventing lifelong disabilities. Vaccines are extremely safe, however, no vaccine is completely free from risks and adverse events can occur following vaccination. An adverse event following immunization (AEFI) may be a true adverse reaction caused by the vaccine or an event that temporally occurred after immunization but is not caused by it. Among the adverse reactions to vaccines, one of the most feared is the triggering of autoimmune diseases, which are a heterogeneous group of disorders characterized by dysregulation of the immune system. Currently, no mechanisms have been demonstrated that could explain the correlation between vaccination and the development of autoimmune diseases. Furthermore, epidemiological studies do not support the hypothesis that vaccines cause systemic autoimmune diseases. The only confirmed associations, although very rare, are those between the flu vaccine and Guillain-Barré syndrome, especially with old vaccine preparations, and measles-mumps-rubella (MMR) vaccine and thrombocytopenia. Due to the SARS-CoV2 pandemic, new types of vaccines have been developed and are now available. Close vaccine safety-surveillance is currently underway for these new vaccines.
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Affiliation(s)
- Bianca Olivieri
- Department of Medicine, School of Specialization in Allergy and Clinical Immunology, University of Verona, 37134 Verona, Italy;
| | - Corrado Betterle
- Department of Medicine (DIMED), Clinical Immunology and Allergy, University of Padua, 35128 Padua, Italy;
| | - Giovanna Zanoni
- Immunology Unit, University Hospital, 37134 Verona, Italy
- Correspondence:
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11
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Nichani P, Micieli JA. Granuloma Annulare, Scalp Necrosis, and Ischemic Optic Neuropathy From Giant Cell Arteritis After Varicella-Zoster Virus Vaccination. J Neuroophthalmol 2021; 41:e145-e148. [PMID: 32235218 DOI: 10.1097/wno.0000000000000947] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Prem Nichani
- Faculty of Medicine (PN), University of Toronto, Toronto, Canada ; Department of Ophthalmology and Vision Sciences (JAM), University of Toronto, Toronto, Canada ; and Division of Neurology (JAM), Department of Medicine, University of Toronto, Toronto, Canada
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12
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Liozon E, Parreau S, Filloux M, Dumonteil S, Gondran G, Bezanahary H, Ly KH, Fauchais AL. Giant cell arteritis or polymyalgia rheumatica after influenza vaccination: A study of 12 patients and a literature review. Autoimmun Rev 2020; 20:102732. [PMID: 33326851 DOI: 10.1016/j.autrev.2020.102732] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 10/24/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are inflammatory rheumatic diseases common in people over the age of 50 years. Seasonal influenza vaccination (IV) is strongly recommended in this population, among whom it is considered to be effective and well tolerated. IV-induced GCA or PMR are thought to be exceptional. PATIENTS AND METHODS We retrieved all post-IV cases from an inception cohort of patients with newly diagnosed GCA. We also included two patients with post-IV PMR and reviewed all published reports of post-IV GCA or PMR, with selection of cases demonstrating disease onset within 1 month following IV. We compared the results of HLA-DRB1 typing, performed in seven patients with post-IV GCA or PMR, with those of 11 GCA patients with familial aggregation and 16 randomly selected GCA patients without a reported trigger. RESULTS Of 358 GCA recruited since 2002, 10 (2.8%) qualified for post-IV GCA, of whom two also showed familial aggregation. Thirty-two patients (19 with GCA and 13 with PMR) including our patients were reviewed; their mean age was 71.8 ± 7.4 years and the M/F ratio was 0.8. Six patients (19%) had a history of PMR. Patients with post-IV GCA/PMR had the DRB1*13:01 haplotype more frequently compared to those with familial GCA (5/7 vs. 2/11, p = 0.048) or with GCA without a known trigger (3/16, p = 0.026). Post-IV PMR generally appeared self-limited, whereas post-IV GCA often displayed a more protracted course (chronic relapsing disease in one-third of the patients). CONCLUSION Post-IV onset of GCA/PMR is not an exceptional occurrence and may be part of the spectrum of the autoimmune syndrome induced by adjuvants (ASIA). IV can trigger GCA or PMR, especially in persons at higher spontaneous risk, such as those with a personal or familial history of GCA/PMR. Whether the presence of the DRB1*13:01 allele further increases the risk of post-IV GCA/PMR through a stronger vaccine-induced immune reaction deserves further investigation. Unlike PMR, GCA can be a serious complication of IV.
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Affiliation(s)
- Eric Liozon
- Departments of Internal Medicine, University Hospital of Limoges, Limoges Cedex, France.
| | - Simon Parreau
- Departments of Internal Medicine, University Hospital of Limoges, Limoges Cedex, France
| | - Matthieu Filloux
- Immunology and Immunogenetics, University Hospital of Limoges, Limoges Cedex, France
| | - Stéphanie Dumonteil
- Departments of Internal Medicine, University Hospital of Limoges, Limoges Cedex, France
| | - Guillaume Gondran
- Departments of Internal Medicine, University Hospital of Limoges, Limoges Cedex, France
| | - Holy Bezanahary
- Departments of Internal Medicine, University Hospital of Limoges, Limoges Cedex, France
| | - K H Ly
- Departments of Internal Medicine, University Hospital of Limoges, Limoges Cedex, France
| | - Anne Laure Fauchais
- Departments of Internal Medicine, University Hospital of Limoges, Limoges Cedex, France
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13
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Polymyalgia rheumatica following infective triggers or vaccinations: a different subset of disease? Reumatologia 2020; 58:76-80. [PMID: 32476679 PMCID: PMC7249527 DOI: 10.5114/reum.2020.95360] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 03/20/2020] [Indexed: 11/17/2022] Open
Abstract
Objectives Polymyalgia rheumatica (PMR) is the commonest inflammatory disorder of the elderly; an association with environmental triggers and a deregulated immune response have been described. The aim of this study was to investigate the association of environmental triggers before the onset of PMR. Material and methods The database of 58 consecutive PMR patients recruited from a single rheumatology secondary care setting was retrospectively analyzed to investigate the frequency of environmental triggers and correlations with clinical characteristics, ultrasound and laboratory data. Results Fifteen PMR patients (26%) described a connection with environmental agents: six PMR patients reported a vaccination, 4 reported a respiratory tract infection, 5 reported seasonal influenza before the onset of the disease. The model of multivariate linear regression which better predicted a shorter time to normalize inflammatory reactants (R2 = 27.46%, p = 0.0042) comprised the presence of an environmental trigger and a higher PCR. A linear regression analysis confirmed an inverse correlation between PCR at onset and time to normalize inflammatory reactant (r = –0.3031, p = 0.0208). A significant correlation was demonstrated between presence of environmental trigger and shorter time to normalize inflammation (r = –0.5215, p< 0.0001), and lesser frequency of gleno-humeral synovitis on US (r = –0.3774, p = 0.0038). Conclusions Our work describes a correlation between environmental triggers in PMR and higher CRP at diagnosis, faster response to therapy, and milder shoulder synovitis. We may suppose that these patients belong to a more specific subtype of PMR, in whom external stimuli, such as vaccination or infection, may lead to a deregulated response within the context of an impaired senescent immuno-endocrine system.
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14
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Bassendine MF, Bridge SH. Relapse of polymyalgia rheumatica following adjuvanted influenza vaccine: A case-based review. Eur J Rheumatol 2019; 7:37-40. [PMID: 31922479 DOI: 10.5152/eurjrheum.2019.19152] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 09/09/2019] [Indexed: 01/18/2023] Open
Abstract
Polymyalgia rheumatica (PMR) is the most common inflammatory rheumatological condition affecting individuals aged >50 years. There have been rare reports of PMR and other vasculitides developing within 3 months of influenza vaccination. Influenza is a major public health issue associated with seasonal increased mortality and intensified health care service use. Annual vaccination is the most effective intervention to prevent influenza, especially in elderly individuals. We report a severe "flare" of PMR in a 70-year-old patient after receiving the adjuvanted trivalent influenza vaccine, as recommended by the Joint Committee on Vaccination and Immunisations for this age group in the UK National Health Service in 2018-2019. The adverse event (AE) could be interpreted as the newly described autoimmune/inflammatory syndrome induced by adjuvants (ASIA syndrome) as both PMR and ASIA display hyperactive immune responses. Caution is warranted in the use of vaccine adjuvants in patients with PMR with pre-existing imbalance of B and T cell homeostasis. Rare AEs are important to individuals, and personalized medicine means we should move away from "one size fits all" for vaccines, as well as for therapeutics.
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Affiliation(s)
- Margaret F Bassendine
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.,Department of Hepatology & Gastroenterology, Imperial College London, London, UK
| | - Simon H Bridge
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.,Northumbria University, School of Health and Life Sciences, Newcastle upon Tyne, UK
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15
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Brault C, Riis AH, Mor A, Duhaut P, Thomsen RW. Does low risk of infections as a marker of effective immunity predict increased risk of subsequent giant cell arteritis or polymyalgia rheumatica? A Danish population-based case-control study. Clin Epidemiol 2018; 10:1533-1543. [PMID: 30425584 PMCID: PMC6201992 DOI: 10.2147/clep.s158293] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Objective It has been suggested that a hyper-effective immune system (“hyper-immunity”) is central to the pathogenesis of giant cell arteritis and polymyalgia rheumatica (GCA/PMR). We examined if a low risk of infections, as a marker of hyper-immunity, can predict increased subsequent risk of GCA/PMR. Patients and methods We conducted a population-based case–control study including all patients aged ≥50 years with incident GCA/PMR diagnosed between 1997 and 2012 in Northern Denmark. For each case, we selected 10 population controls matched on gender, age, place of residence, and time spent in the region. Complete history of hospital-treated infections and community-based anti-infective prescriptions was assessed in population-based registries. We used conditional logistic regression to compute OR of GCA/PMR associated with infections while adjusting for comorbidities, immunosuppressive treatment, and other potential confounders. Results We included 7,225 GCA/PMR cases and 72,250 controls. When excluding all infections occurring within the last year before GCA/PMR diagnosis, there was no decreased risk for GCA/PMR in people with a history of hospital-treated infection (adjusted OR=1.04, 95% CI: 0.98–1.10) or community anti-infective treatment (adjusted OR=1.07, 95% CI: 0.99–1.16). Within the last year preceding the GCA/PMR index date, patients with hospital-treated infections (adjusted OR=1.59, 95% CI: 1.44–1.75) or community anti-infective treatment (adjusted OR=1.63, 95% CI: 1.48–1.79) had a greatly increased risk of a GCA/PMR diagnosis. Conclusion These results do not support the hypothesis of “hyper-immunity” leading to GCA/PMR. Instead, incident GCA/PMR is preceded by a slightly increased risk of infection, which may be related to protopathic bias or support theories that infections may be directly involved in the pathogenesis of GCA/PMR.
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Affiliation(s)
- Clément Brault
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark, .,Department of Internal Medicine and RECIF, Amiens-Picardie University Hospital, Amiens, France,
| | - Anders H Riis
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark,
| | - Anil Mor
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark,
| | - Pierre Duhaut
- Department of Internal Medicine and RECIF, Amiens-Picardie University Hospital, Amiens, France,
| | - Reimar W Thomsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark,
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16
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Polymyalgia Rheumatica and Autoimmune Inflammatory Syndrome Induced by Adjuvants Following Administration of Influenza Vaccine. J Clin Rheumatol 2018; 24:410-412. [DOI: 10.1097/rhu.0000000000000712] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Kanzaki A, Matsui K, Sukenaga T, Mase K, Nishioka A, Tamori T, Kataoka S, Konya H, Mizutani S, Takeda A, Koseki M, Nishiura T, Koyama H, Sano H. Fever of unknown origin following parathyroidectomy prior to onset of typical polymyalgia rheumatica symptoms: a case report. Int J Gen Med 2018; 11:307-311. [PMID: 30038516 PMCID: PMC6052921 DOI: 10.2147/ijgm.s159364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Polymyalgia rheumatica (PMR) is a disease commonly seen in elderly individuals, however, the etiology has not been reported. Typical clinical features include bilateral shoulder pain and morning stiffness, while serologic autoantibody test findings are negative. Approximately 40%–50% of affected patients present with low-grade fever, fatigue, and appetite loss, which we often experience in the field of general medicine, and thus, the condition should not be given low priority. However, knowledge regarding such constitutional manifestations is also limited. We encountered an elderly woman with a fever of unknown origin that developed following a parathyroidectomy for a single parathyroid adenoma, after which severe shoulder pain and morning stiffness emerged, leading to a diagnosis of PMR. The fever developed several days prior to appearance of severe pain, which is an uncommon presentation in PMR cases. Our patient had low-grade inflammation without pyrexia prior to the surgery, which might have been an important reason for the accelerated immoderate immune activation leading to PMR induced by surgery in this case. Furthermore, she was infected with the influenza A virus 3 weeks before coming to us. Some reports have suggested a relationship between the influenza virus or vaccine and PMR. It is difficult to conclude regarding the definite trigger in our patient, though the details of this case should be helpful for a better understanding of the disease.
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Affiliation(s)
- Akinori Kanzaki
- Department of Internal Medicine, Ashiya Municipal Hospital, Ashiya, Hyogo, Japan, .,Division of Diabetes, Endocrinology and Metabolism, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan,
| | - Kiyoshi Matsui
- Division of Rheumatology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Tadahiko Sukenaga
- Department of Internal Medicine, Ashiya Municipal Hospital, Ashiya, Hyogo, Japan, .,Division of Diabetes, Endocrinology and Metabolism, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan,
| | - Koushi Mase
- Department of Internal Medicine, Ashiya Municipal Hospital, Ashiya, Hyogo, Japan,
| | - Aya Nishioka
- Department of Internal Medicine, Ashiya Municipal Hospital, Ashiya, Hyogo, Japan,
| | - Tomoharu Tamori
- Department of Surgery, Ashiya Municipal Hospital, Ashiya, Hyogo, Japan
| | - Seiko Kataoka
- Department of Internal Medicine, Ashiya Municipal Hospital, Ashiya, Hyogo, Japan,
| | - Hiroyuki Konya
- Department of Internal Medicine, Ashiya Municipal Hospital, Ashiya, Hyogo, Japan,
| | - Shin Mizutani
- Department of Surgery, Ashiya Municipal Hospital, Ashiya, Hyogo, Japan
| | - Akira Takeda
- Department of Internal Medicine, Ashiya Municipal Hospital, Ashiya, Hyogo, Japan,
| | - Masato Koseki
- Department of Internal Medicine, Ashiya Municipal Hospital, Ashiya, Hyogo, Japan,
| | - Tetsuo Nishiura
- Department of Internal Medicine, Ashiya Municipal Hospital, Ashiya, Hyogo, Japan,
| | - Hidenori Koyama
- Division of Diabetes, Endocrinology and Metabolism, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan,
| | - Hajime Sano
- Division of Rheumatology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
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18
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The value of Autoimmune Syndrome Induced by Adjuvant (ASIA) - Shedding light on orphan diseases in autoimmunity. Autoimmun Rev 2018. [DOI: 10.1016/j.autrev.2017.11.037] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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19
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Polymyalgia Rheumatica After Herpes-Zoster. Arch Rheumatol 2018; 33:494-495. [PMID: 30874245 DOI: 10.5606/archrheumatol.2018.6859] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Accepted: 02/03/2018] [Indexed: 11/21/2022] Open
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20
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Eindhoven S, Levels J, Huisman M, de Winter KR, Dalm V, Alwani R. MPO-ANCA associated vasculitis with mononeuritis multiplex following influenza vaccination. Allergy Asthma Clin Immunol 2017; 13:49. [PMID: 29255476 PMCID: PMC5727957 DOI: 10.1186/s13223-017-0222-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 11/06/2017] [Indexed: 11/14/2022] Open
Abstract
Background Although influenza vaccines are generally safe and effective, a variety of autoimmune phenomena have been reported after vaccination over the past years, such as Guillain–Barre syndrome, rheumatoid arthritis, pemphigus vulgaris, psoriasis, giant cell arteritis and anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV). Case report We describe the case of a 67-year old man who presented with a myeloperoxidase-ANCA associated vasculitis with renal involvement and mononeuritis multiplex after seasonal influenza vaccination. He was initially treated with intravenous cyclophosphamide and high-dose prednisolone followed by maintenance treatment consisting of azathioprine and prednisolone. Conclusion We hypothesize that seasonal influenza vaccination triggered a systemic immune response in a susceptible patient to develop AAV with renal involvement and vasculitic neuropathy. In general, seasonal influenza vaccinations are considered to be safe, however, clinicians should be aware of this rare phenomenon.
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Affiliation(s)
- Stefanie Eindhoven
- Department of Internal Medicine, IJsselland Hospital, Capelle aan den IJssel, The Netherlands.,Department of Internal Medicine, Room F104, IJsselland Hospital, P.O. Box 690, 2900 AR Capelle aan den IJssel, The Netherlands
| | - Jolien Levels
- Department of Internal Medicine, IJsselland Hospital, Capelle aan den IJssel, The Netherlands
| | - Margriet Huisman
- Division of Rheumatology, Department of Internal Medicine, IJsselland Hospital, Capelle aan den IJssel, The Netherlands
| | | | - Virgil Dalm
- Division of Clinical Immunology, Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands.,Department of Immunology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Rehmat Alwani
- Department of Internal Medicine, IJsselland Hospital, Capelle aan den IJssel, The Netherlands
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21
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Skevaki C, Hudemann C, Matrosovich M, Möbs C, Paul S, Wachtendorf A, Alashkar Alhamwe B, Potaczek DP, Hagner S, Gemsa D, Garn H, Sette A, Renz H. Influenza-derived peptides cross-react with allergens and provide asthma protection. J Allergy Clin Immunol 2017; 142:804-814. [PMID: 29132960 DOI: 10.1016/j.jaci.2017.07.056] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 07/04/2017] [Accepted: 07/19/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND The hygiene hypothesis is the leading concept to explain the current asthma epidemic, which is built on the observation that a lack of bacterial contact early in life induces allergic TH2 immune responses. OBJECTIVE Because little is known about the contribution of respiratory tract viruses in this context, we evaluated the effect of prior influenza infection on the development of allergic asthma. METHODS Mice were infected with influenza and, once recovered, subjected to an ovalbumin- or house dust mite-induced experimental asthma protocol. Influenza-polarized effector memory T (Tem) cells were transferred adoptively to allergen-sensitized animals before allergen challenge. A comprehensive in silico analysis assessed homologies between virus- and allergen-derived proteins. Influenza-polarized Tem cells were stimulated ex vivo with candidate peptides. Mice were immunized with a pool of virus-derived T-cell epitopes. RESULTS In 2 murine models we found a long-lasting preventive effect against experimental asthma features. Protection could be attributed about equally to CD4+ and CD8+ Tem cells from influenza-infected mice. An in silico bioinformatic analysis identified 4 influenza- and 3 allergen-derived MHC class I and MHC class II candidate T-cell epitopes with potential antigen-specific cross-reactivity between influenza and allergens. Lymphocytes from influenza-infected mice produced IFN-γ and IL-2 but not IL-5 on stimulation with the aforementioned peptides. Immunization with a mixture of the influenza peptides conferred asthma protection, and peptide-immunized mice transferred protection through CD4+ and CD8+ Tem cells. CONCLUSION For the first time, our results illustrate heterologous immunity of virus-infected animals toward allergens. This finding extends the original hygiene hypothesis.
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Affiliation(s)
- Chrysanthi Skevaki
- Institute of Laboratory Medicine and Pathobiochemistry, Member of the German Center for Lung Research (DZL), Philipps University Marburg, Marburg, Germany
| | - Christoph Hudemann
- Institute of Laboratory Medicine and Pathobiochemistry, Member of the German Center for Lung Research (DZL), Philipps University Marburg, Marburg, Germany
| | | | - Christian Möbs
- Department of Dermatology and Allergology, Philipps University Marburg, Marburg, Germany
| | - Sinu Paul
- La Jolla Institute for Allergy and Immunology, La Jolla, Calif
| | - Andreas Wachtendorf
- Institute of Laboratory Medicine and Pathobiochemistry, Member of the German Center for Lung Research (DZL), Philipps University Marburg, Marburg, Germany
| | - Bilal Alashkar Alhamwe
- Institute of Laboratory Medicine and Pathobiochemistry, Member of the German Center for Lung Research (DZL), Philipps University Marburg, Marburg, Germany
| | - Daniel P Potaczek
- Institute of Laboratory Medicine and Pathobiochemistry, Member of the German Center for Lung Research (DZL), Philipps University Marburg, Marburg, Germany; John Paul II Hospital, Krakow, Poland
| | - Stefanie Hagner
- Institute of Laboratory Medicine and Pathobiochemistry, Member of the German Center for Lung Research (DZL), Philipps University Marburg, Marburg, Germany
| | - Diethard Gemsa
- Institute of Laboratory Medicine and Pathobiochemistry, Member of the German Center for Lung Research (DZL), Philipps University Marburg, Marburg, Germany
| | - Holger Garn
- Institute of Laboratory Medicine and Pathobiochemistry, Member of the German Center for Lung Research (DZL), Philipps University Marburg, Marburg, Germany
| | | | - Harald Renz
- Institute of Laboratory Medicine and Pathobiochemistry, Member of the German Center for Lung Research (DZL), Philipps University Marburg, Marburg, Germany.
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22
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Watad A, Quaresma M, Brown S, Cohen Tervaert JW, Rodríguez-Pint I, Cervera R, Perricone C, Shoenfeld Y. Autoimmune/inflammatory syndrome induced by adjuvants (Shoenfeld’s syndrome) – An update. Lupus 2017; 26:675-681. [DOI: 10.1177/0961203316686406] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Autoimmune/inflammatory syndrome induced by adjuvants (ASIA) has been widely described in many studies conducted thus far. The syndrome incorporates five immune-mediated conditions, all associated with previous exposure to various agents such as vaccines, silicone implants and several others. The emergence of ASIA syndrome is associated with individual genetic predisposition, for instance those carrying HLA-DRB1*01 or HLA-DRB4 and results from exposure to external or endogenous factors triggering autoimmunity. Such factors have been demonstrated as able to induce autoimmunity in both animal models and humans via a variety of proposed mechanisms. In recent years, physicians have become more aware of the existence of ASIA syndrome and the relationship between adjuvants exposure and autoimmunity and more cases are being reported. Accordingly, we have created a registry that includes at present more than 300 ASIA syndrome cases that have been reported by different physicians worldwide, describing various autoimmune conditions induced by diverse adjuvants. In this review, we have summarized the updated literature on ASIA syndrome and the knowledge accumulated since 2013 in order to elucidate the association between the exposure to various adjuvant agents and its possible clinical manifestations. Furthermore, we especially referred to the relationship between ASIA syndrome and systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS).
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Affiliation(s)
- A Watad
- Department of Medicine B, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Israel
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Israel
| | - M Quaresma
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Israel
| | - S Brown
- Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | | | | | - R Cervera
- Department of Autoimmune Diseases, Hospital Clinic, Spain
| | - C Perricone
- Reumatologia, Dipartimento di Medicina Interna e Specialita Mediche, Sapienza Universita di Roma, Italy
| | - Y Shoenfeld
- Department of Medicine B, Sheba Medical Center, Tel-Hashomer, Israel
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Israel
- Incumbent of the Laura Schwarz-Kipp Chair for Research of Autoimmune Diseases, Tel-Aviv University, Israel
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23
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Watad A, Sharif K, Shoenfeld Y. The ASIA syndrome: basic concepts. Mediterr J Rheumatol 2017; 28:64-69. [PMID: 32185259 PMCID: PMC7046028 DOI: 10.31138/mjr.28.2.64] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 05/27/2017] [Accepted: 06/04/2017] [Indexed: 12/02/2022] Open
Abstract
The autoimmune/inflammatory syndrome induced by adjuvants (ASIA), also known as Shoenfeld's syndrome, encompasses several autoimmune conditions/phenomena that are induced following the exposure to substances with adjuvant activity. The disease spectrum is heterogeneous in respect to clinical presentation as well as severity of the clinical manifestations. Adjuvants are included in vaccination formulations for their immunogenic properties. Despite being generally well tolerated, safe and effective, some genetically predisposed individuals can develop generalized non-specific constitutional symptoms, autoantibody production, new onset, or worsening of disease presentation. In this review, we focus on the current knowledge presented in the literature on ASIA syndrome, increasing physician awareness about the basic concepts of ASIA syndrome and highlight the devastating amount of data accumulated in the last few years concerning the relationship between various adjuvants and autoimmunity.
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Affiliation(s)
- Abdulla Watad
- Department of Medicine ‘B’
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Kassem Sharif
- Department of Medicine ‘B’
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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24
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Jara LJ, García-Collinot G, Medina G, Cruz-Dominguez MDP, Vera-Lastra O, Carranza-Muleiro RA, Saavedra MA. Severe manifestations of autoimmune syndrome induced by adjuvants (Shoenfeld’s syndrome). Immunol Res 2016; 65:8-16. [DOI: 10.1007/s12026-016-8811-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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25
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Abstract
Polymyalgia rheumatica (PMR) is relatively common among the elderly, and is characterized by multiple body aches with an elevated erythrocyte sedimentation rate. Even though the etiology of PMR remains unknown, a number of infectious agents have been suggested to cause PMR. Also, there are reports of PMR after influenza vaccination. The exact role of influenza vaccination on the development of PMR remains unknown, but may be associated with specific human leukocyte antigens (HLAs), such as HLA-DRB1 and HLA-DQB1. Whether postvaccination PMR is caused by influenza virus antigen or adjuvants in the vaccine is another unanswered question. We herein report a case of an 85-year-old woman who developed PMR shortly after contracting influenza virus B. Even though infections are hypothesized to be one of the causes of PMR, this is the first-ever case of PMR following influenza virus infection. Further studies may elucidate the exact role of influenza virus infection on the etiology and pathogenesis of PMR.
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Affiliation(s)
- Kentaro Iwata
- Division of Infectious Diseases, Kobe University Hospital, Kobe, Japan
| | - Yasushi Mizuno
- Department of General Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
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26
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Bonetto C, Trotta F, Felicetti P, Alarcón GS, Santuccio C, Bachtiar NS, Brauchli Pernus Y, Chandler R, Girolomoni G, Hadden RDM, Kucuku M, Ozen S, Pahud B, Top K, Varricchio F, Wise RP, Zanoni G, Živković S, Bonhoeffer J. Vasculitis as an adverse event following immunization - Systematic literature review. Vaccine 2015; 34:6641-6651. [PMID: 26398442 DOI: 10.1016/j.vaccine.2015.09.026] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 09/10/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Several types of vasculitis have been observed and reported in temporal association with the administration of various vaccines. A systematic review of current evidence is lacking. OBJECTIVE This systematic literature review aimed to assess available evidence and current reporting practice of vasculitides as adverse events following immunization (AEFI). METHODS We reviewed the literature from 1st January 1994 to 30th June 2014. This review comprises randomized controlled trials, observational studies, case series, case reports, reviews and comments regardless of vaccine and target population. RESULTS The initial search resulted in the identification of 6656 articles. Of these, 157 articles were assessed for eligibility and 75 studies were considered for analysis, including 6 retrospective/observational studies, 2 randomized controlled trials, 7 reviews, 11 case series, 46 case reports and 3 comments. Most of the larger, higher quality studies found no causal association between vaccination and subsequent development of vasculitis, including several studies on Kawasaki disease and Henoch-Schönlein purpura (IgA vasculitis). Smaller case series reported a few cases of vasculitis following BCG and vaccines against influenza and hepatitis. Only 24% of the articles reported using a case definition of vasculitis. CONCLUSIONS Existing literature does not allow establishing a causative link between vaccination and vasculitides. Further investigations were strengthened by the use of standardized case definitions and methods for data collection, analysis and presentation to improve data comparability and interpretation of vasculitis cases following immunization.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Giampiero Girolomoni
- Department of Medicine, Section of Dermatology and Venereology, University of Verona, Verona, Italy
| | | | - Merita Kucuku
- Department of Vaccines Control, National Agency for Medicines and Medical Devices, Tirana, Albania
| | - Seza Ozen
- Department of Pediatric Rheumatology, Hacettepe University, Ankara, Turkey
| | | | - Karina Top
- Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | | | - Giovanna Zanoni
- Immunology Unit, Policlinico G.B. Rossi, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Saša Živković
- University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Jan Bonhoeffer
- Brighton Collaboration Foundation, Basel, Switzerland; University of Basel Children's Hospital, Basel, Switzerland
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27
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Guimarães LE, Baker B, Perricone C, Shoenfeld Y. Vaccines, adjuvants and autoimmunity. Pharmacol Res 2015; 100:190-209. [PMID: 26275795 PMCID: PMC7129276 DOI: 10.1016/j.phrs.2015.08.003] [Citation(s) in RCA: 138] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 08/05/2015] [Indexed: 12/15/2022]
Abstract
Vaccines and autoimmunity are linked fields. Vaccine efficacy is based on whether host immune response against an antigen can elicit a memory T-cell response over time. Although the described side effects thus far have been mostly transient and acute, vaccines are able to elicit the immune system towards an autoimmune reaction. The diagnosis of a definite autoimmune disease and the occurrence of fatal outcome post-vaccination have been less frequently reported. Since vaccines are given to previously healthy hosts, who may have never developed the disease had they not been immunized, adverse events should be carefully accessed and evaluated even if they represent a limited number of occurrences. In this review of the literature, there is evidence of vaccine-induced autoimmunity and adjuvant-induced autoimmunity in both experimental models as well as human patients. Adjuvants and infectious agents may exert their immune-enhancing effects through various functional activities, encompassed by the adjuvant effect. These mechanisms are shared by different conditions triggered by adjuvants leading to the autoimmune/inflammatory syndrome induced by adjuvants (ASIA syndrome). In conclusion, there are several case reports of autoimmune diseases following vaccines, however, due to the limited number of cases, the different classifications of symptoms and the long latency period of the diseases, every attempt for an epidemiological study has so far failed to deliver a connection. Despite this, efforts to unveil the connection between the triggering of the immune system by adjuvants and the development of autoimmune conditions should be undertaken. Vaccinomics is a field that may bring to light novel customized, personalized treatment approaches in the future.
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Affiliation(s)
- Luísa Eça Guimarães
- The Zabludowicz Center for Autoimmune Diseases, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Britain Baker
- The Zabludowicz Center for Autoimmune Diseases, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Carlo Perricone
- Reumatologia, Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Italy
| | - Yehuda Shoenfeld
- The Zabludowicz Center for Autoimmune Diseases, Chaim Sheba Medical Center, Tel-Hashomer, Israel; Incumbent of the Laura Schwarz-kipp chair for research of autoimmune diseases, Sackler Faculty of Medicine, Tel-Aviv University, Israel.
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28
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Esposito S, Prada E, Mastrolia MV, Tarantino G, Codecà C, Rigante D. Autoimmune/inflammatory syndrome induced by adjuvants (ASIA): clues and pitfalls in the pediatric background. Immunol Res 2015; 60:366-75. [PMID: 25395340 DOI: 10.1007/s12026-014-8586-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The development and increasing diffusion of new vaccinations and global immunization protocols have aroused burning debates about safety of adjuvants and their immunogenicity-enhancing effect in vaccines. Shoenfeld and Agmon-Levin have grouped under the term "autoimmune/inflammatory syndrome induced by adjuvants" (ASIA) a complex of variable signs and symptoms that may occur after a previous exposure to different adjuvants and also external environmental triggers, even eliciting specific overt immune-mediated disorders. This entity subsumes five medical conditions: post-vaccination phenomena, gulf war syndrome, macrophagic myofasciitis syndrome, siliconosis, and sick building syndrome, but the relevance and magnitude of the syndrome in the pediatric age is fundamentally limited to post-vaccination autoimmune or inflammatory disorders. The occurrence of vaccine-triggered phenomena represents a diagnostic challenge for clinicians and a research conundrum for many investigators. In this paper, we will analyze the general features of ASIA and focus on specific post-vaccination events in relation with the pediatric background. In the presence of a favorable genetic background, many autoimmune/inflammatory responses can be triggered by adjuvants and external factors, showing how the man himself might breach immune tolerance and drive many pathogenetic aspects of human diseases. Nonetheless, the elective application of ASIA diagnostic criteria to the pediatric population requires further assessment and evaluations. Additional studies are needed to help clarify connections between innate or adaptive immunity and pathological and/or protective autoantibodies mostly in the pediatric age, as children and adolescents are mainly involved in the immunization agendas related to vaccine-preventable diseases.
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Affiliation(s)
- Susanna Esposito
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, Via Commenda 9, 20122, Milan, Italy,
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29
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[Temporal arteritis with normal erythrocyte sedimentation rate]. Rev Esp Geriatr Gerontol 2015; 50:299-300. [PMID: 26168777 DOI: 10.1016/j.regg.2015.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 04/29/2015] [Accepted: 05/04/2015] [Indexed: 11/20/2022]
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Revisiting adverse reactions to vaccines: A critical appraisal of Autoimmune Syndrome Induced by Adjuvants (ASIA). J Autoimmun 2015; 59:77-84. [DOI: 10.1016/j.jaut.2015.02.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Revised: 02/23/2015] [Accepted: 02/23/2015] [Indexed: 01/01/2023]
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Soriano A, Nesher G, Shoenfeld Y. Predicting post-vaccination autoimmunity: who might be at risk? Pharmacol Res 2014; 92:18-22. [PMID: 25277820 DOI: 10.1016/j.phrs.2014.08.002] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2014] [Revised: 08/12/2014] [Accepted: 08/14/2014] [Indexed: 01/06/2023]
Abstract
Vaccinations have been used as an essential tool in the fight against infectious diseases, and succeeded in improving public health. However, adverse effects, including autoimmune conditions may occur following vaccinations (autoimmune/inflammatory syndrome induced by adjuvants--ASIA syndrome). It has been postulated that autoimmunity could be triggered or enhanced by the vaccine immunogen contents, as well as by adjuvants, which are used to increase the immune reaction to the immunogen. Fortunately, vaccination-related ASIA is uncommon. Yet, by defining individuals at risk we may further limit the number of individuals developing post-vaccination ASIA. In this perspective we defined four groups of individuals who might be susceptible to develop vaccination-induced ASIA: patients with prior post-vaccination autoimmune phenomena, patients with a medical history of autoimmunity, patients with a history of allergic reactions, and individuals who are prone to develop autoimmunity (having a family history of autoimmune diseases; asymptomatic carriers of autoantibodies; carrying certain genetic profiles, etc.).
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Affiliation(s)
- Alessandra Soriano
- Department of Clinical Medicine and Rheumatology, Campus Bio-Medico University, Rome, Italy
| | - Gideon Nesher
- Department of Internal Medicine A, Shaare Zedek Medical Center, and the Hebrew University Medical School, Jerusalem, Israel.
| | - Yehuda Shoenfeld
- The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Sackler Faculty of Medicine, Incumbent of the Laura Schwarz-Kip Chair for Research of Autoimmune Diseases, Tel-Aviv University, Israel
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Gerardi MC, Rutigliano IM, Scrivo R, Priori R, Riccieri V, Valesini G. "In sickness and in health": the peculiar occurrence of polymyalgia rheumatica in married cohabiting couples--a case series and review of the literature. Clin Rheumatol 2014; 35:1111-5. [PMID: 24728878 DOI: 10.1007/s10067-014-2604-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 03/30/2014] [Indexed: 12/20/2022]
Abstract
Polymyalgia rheumatica (PMR) is an inflammatory rheumatic disorder in elderly people. It is frequently associated with giant-cell arteritis (GCA), although it is still debated if they are the same disease or two distinct pathologies. The etiology of PMR remains challenging, although current knowledge supports the role of both genetic and environmental factors. Among these, there is evidence that infectious agents could trigger the disease's onset in some cases. We describe the peculiar case where PMR occurred in two Italian married and cohabiting couples and provide a review of the literature for similar cases. This is the first reported occurrence of PMR in two conjugal pairs in Italy. Moreover, in the second case, the wife presented PMR associated with GCA. To date, seven cases of PMR and two of GCA in married couples are described in the literature. The occurrence of PMR in both a husband and a wife supports the pathogenetic role of an environmental factor.
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Affiliation(s)
- Maria Chiara Gerardi
- Dipartimento di Medicina Interna e Specialità Mediche, Reumatologia, Sapienza Università di Roma, Viale del Policlinico 155, 00161, Rome, Italy
| | - Iolanda Maria Rutigliano
- Dipartimento di Medicina Interna e Specialità Mediche, Reumatologia, Sapienza Università di Roma, Viale del Policlinico 155, 00161, Rome, Italy
| | - Rossana Scrivo
- Dipartimento di Medicina Interna e Specialità Mediche, Reumatologia, Sapienza Università di Roma, Viale del Policlinico 155, 00161, Rome, Italy
| | - Roberta Priori
- Dipartimento di Medicina Interna e Specialità Mediche, Reumatologia, Sapienza Università di Roma, Viale del Policlinico 155, 00161, Rome, Italy.
| | - Valeria Riccieri
- Dipartimento di Medicina Interna e Specialità Mediche, Reumatologia, Sapienza Università di Roma, Viale del Policlinico 155, 00161, Rome, Italy
| | - Guido Valesini
- Dipartimento di Medicina Interna e Specialità Mediche, Reumatologia, Sapienza Università di Roma, Viale del Policlinico 155, 00161, Rome, Italy
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Perricone C, Colafrancesco S, Mazor RD, Soriano A, Agmon-Levin N, Shoenfeld Y. Autoimmune/inflammatory syndrome induced by adjuvants (ASIA) 2013: Unveiling the pathogenic, clinical and diagnostic aspects. J Autoimmun 2013; 47:1-16. [PMID: 24238833 DOI: 10.1016/j.jaut.2013.10.004] [Citation(s) in RCA: 161] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 10/21/2013] [Indexed: 12/23/2022]
Abstract
In 2011 a new syndrome termed 'ASIA Autoimmune/Inflammatory Syndrome Induced by Adjuvants' was defined pointing to summarize for the first time the spectrum of immune-mediated diseases triggered by an adjuvant stimulus such as chronic exposure to silicone, tetramethylpentadecane, pristane, aluminum and other adjuvants, as well as infectious components, that also may have an adjuvant effect. All these environmental factors have been found to induce autoimmunity by themselves both in animal models and in humans: for instance, silicone was associated with siliconosis, aluminum hydroxide with post-vaccination phenomena and macrophagic myofasciitis syndrome. Several mechanisms have been hypothesized to be involved in the onset of adjuvant-induced autoimmunity; a genetic favorable background plays a key role in the appearance on such vaccine-related diseases and also justifies the rarity of these phenomena. This paper will focus on protean facets which are part of ASIA, focusing on the roles and mechanisms of action of different adjuvants which lead to the autoimmune/inflammatory response. The data herein illustrate the critical role of environmental factors in the induction of autoimmunity. Indeed, it is the interplay of genetic susceptibility and environment that is the major player for the initiation of breach of tolerance.
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Affiliation(s)
- Carlo Perricone
- The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel; Reumatologia, Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Rome, Italy
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Vera-Lastra O, Medina G, Cruz-Dominguez MDP, Jara LJ, Shoenfeld Y. Autoimmune/inflammatory syndrome induced by adjuvants (Shoenfeld's syndrome): clinical and immunological spectrum. Expert Rev Clin Immunol 2013; 9:361-73. [PMID: 23557271 DOI: 10.1586/eci.13.2] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
An adjuvant is a substance that enhances the antigen-specific immune response, induces the release of inflammatory cytokines, and interacts with Toll-like receptors and the NALP3 inflammasome. The immunological consequence of these actions is to stimulate the innate and adaptive immune response. The activation of the immune system by adjuvants, a desirable effect, could trigger manifestations of autoimmunity or autoimmune disease. Recently, a new syndrome was introduced, autoimmune/inflammatory syndrome induced by adjuvants (ASIA), that includes postvaccination phenomena, macrophagic myofasciitis, Gulf War syndrome and siliconosis. This syndrome is characterized by nonspecific and specific manifestations of autoimmune disease. The main substances associated with ASIA are squalene (Gulf War syndrome), aluminum hydroxide (postvaccination phenomena, macrophagic myofasciitis) and silicone with siliconosis. Mineral oil, guaiacol and iodine gadital are also associated with ASIA. The following review describes the wide clinical spectrum and pathogenesis of ASIA including defined autoimmune diseases and nonspecific autoimmune manifestations, as well as the outlook of future research in this field.
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Affiliation(s)
- Olga Vera-Lastra
- Hospital de Especialidades Centro Médico La Raza, Instituto Mexicano del Seguro Social, Mexico City, Mexico
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Vaccination and auto-immune rheumatic diseases: lessons learnt from the 2009 H1N1 influenza virus vaccination campaign. Curr Opin Rheumatol 2013; 25:164-70. [PMID: 23370371 DOI: 10.1097/bor.0b013e32835d2b7b] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE OF REVIEW To determine the safety and efficacy of adjuvant and nonadjuvant influenza A/H1NI vaccination in patients with rheumatic diseases. RECENT FINDINGS Due to immune abnormalities and the use of steroids and immunosuppressant treatment, patients with rheumatic diseases are susceptible to infections including influenza. Infections continue to be one of the leading causes of morbidity and mortality in rheumatic diseases, partly due to the disease processes and partly due to medications. Viral infections are particularly an issue, so vaccinations would be advisable. However, because of the abnormalities in immune mechanisms in many rheumatic diseases, it is not clear whether vaccinations are well tolerated and effective. A number of studies confirmed the efficacy and safety of adjuvant and nonadjuvant influenza A/H1NI vaccination in patients with rheumatic diseases. The potential side effects associated with H1N1 vaccines were not different from those observed with seasonal influenza vaccine. The use of steroids and immunosuppressant therapies may alter the efficacy of the vaccines. Adjuvant and nonadjuvant influenza A/H1NI vaccinations have no clinically important effect on production or levels of autoantibodies in patients with rheumatic diseases. SUMMARY H1N1 vaccination should be given to patients with rheumatic diseases.
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Soriano A, Landolfi R, Manna R. Polymyalgia rheumatica in 2011. Best Pract Res Clin Rheumatol 2013; 26:91-104. [PMID: 22424196 DOI: 10.1016/j.berh.2012.01.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Revised: 01/03/2012] [Accepted: 01/04/2012] [Indexed: 01/30/2023]
Abstract
Polymyalgia Rheumatica (PMR) is an inflammatory rheumatic disease that commonly affects individuals over 50 years of age, characterised by pain and morning stiffness of the shoulder and pelvic girdle. PMR can present as 'isolated' form or may be associated with giant cell arteritis. The progress of imaging techniques has helped in understanding different clinical patterns: subclinical vasculitis can occur in at least one-third of PMR patients, causing ischaemic complications. It is considered a polygenic disease and environmental factors may play a role in its pathogenesis, such as viral or bacterial triggers, both in the 'wide' form or assembled with adjuvants in vaccines. The response to steroid therapy is generally dramatic and side effects may occur, as well as the development of glucocorticoid resistance. The optimisation of therapy may require steroid-sparing agents as well as modified-release prednisone as 'nighttime' replacement therapy.
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Affiliation(s)
- Alessandra Soriano
- Clinical Autoimmunity Unit - Periodic Fever Research Centre, Catholic University of the Sacred Heart, L.go F. Vito N1, 00168 Rome, Italy
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Soriano A, Manna R. Quantifying the efficacy of influenza vaccines. THE LANCET. INFECTIOUS DISEASES 2012; 12:659-60; author reply 660-1. [PMID: 22917097 DOI: 10.1016/s1473-3099(12)70183-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Soriano A, Manna R. Giant cell arteritis and polymyalgia rheumatica after influenza vaccination: comparing different experiences. J Dermatol 2012; 39:888-9. [PMID: 22671765 DOI: 10.1111/j.1346-8138.2012.01594.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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From the Literature. Mol Diagn Ther 2012. [DOI: 10.1007/bf03262208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Agmon-Levin N, Hughes GRV, Shoenfeld Y. The spectrum of ASIA: 'Autoimmune (Auto-inflammatory) Syndrome induced by Adjuvants'. Lupus 2012; 21:118-20. [PMID: 22235040 DOI: 10.1177/0961203311429316] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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