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Ammitzbøll C, Thomsen MK, Bartels LE, Hansen CB, Hermansen MLF, Hänel M, Klose-Jensen R, Larsen ML, Lauritsen MO, Mistegaard CE, Mikkelsen S, Olesen JBM, Næser EU, Nielsen MA, Erikstrup C, Garred P, Hauge EM, Troldborg A. COVID-19 Vaccination Before Initiating Rituximab Treatment Induces Strong Serological Response in Autoimmune Rheumatic Disease, Reducing Post-Pandemic Concerns About the Impact of Rituximab. ACR Open Rheumatol 2024. [PMID: 38923834 DOI: 10.1002/acr2.11681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 04/06/2024] [Accepted: 04/12/2024] [Indexed: 06/28/2024] Open
Abstract
OBJECTIVE Rituximab (RTX)-treated patients exhibit suboptimal responses to COVID-19 vaccines. However, existing research primarily involves patients already receiving RTX when vaccines were introduced, failing to account for the current landscape where patients are vaccinated before initiating RTX. Our objective was to compare the serological response to COVID-19 vaccines in patients vaccinated before or after RTX initiation. METHODS We included 254 RTX-treated patients with autoimmune inflammatory rheumatic diseases (AIIRDs) and 113 blood donors (BDs) in a retrospective, observational cohort study. Patients were categorized based on the timing of RTX treatment relative to primary COVID-19 vaccination. Serological vaccine responses were assessed using three immunoassays, and logistic regression analysis was used to identify predictors of serological response. RESULTS Patients vaccinated before initiating RTX treatment had significantly higher seroconversion rates of SARS-CoV-2 immunoglobulin G (87%) and neutralizing antibodies (91%) compared with those receiving RTX before and after vaccination (n = 132) (61% and 65%, respectively). In the logistic regression analysis, a positive serological response was associated with the number of vaccines administered >9 months after the last RTX treatment. Patients receiving the highest number of vaccines with >9 months after RTX showed a response comparable to that of the BDs. CONCLUSION Vaccinating before RTX initiation yields a robust serological response in patients with AIIRDs. Furthermore, we highlight the reversibility of antibody impairment after RTX treatment cessation, provided that adequate vaccinations occur within a minimum of 9 months after RTX. Our findings offer essential insights for clinical decision-making regarding COVID-19 vaccination and RTX treatment, alleviating concerns about future RTX use.
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Affiliation(s)
| | | | | | - Cecilie Bo Hansen
- Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | | | - Mathias Hänel
- Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | | | - Mads Lamm Larsen
- Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | | | | | | | | | | | | | | | - Peter Garred
- Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | | | - Anne Troldborg
- Aarhus University Hospital and Aarhus University, Aarhus, Denmark
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2
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Torres-Rufas M, Vicente-Rabaneda EF, Cardeñoso L, Gutierrez A, Bong DA, Valero-Martínez C, Serra López-Matencio JM, García-Vicuña R, González-Gay MA, González-Álvaro I, Castañeda S. Effectiveness and Safety of the COVID-19 Vaccine in Patients with Rheumatoid Arthritis in a Real-World Setting. Vaccines (Basel) 2024; 12:672. [PMID: 38932401 PMCID: PMC11209506 DOI: 10.3390/vaccines12060672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 06/06/2024] [Accepted: 06/13/2024] [Indexed: 06/28/2024] Open
Abstract
Novel mechanisms of COVID-19 vaccines raised concern about their potential immunogenicity in patients with rheumatoid arthritis (RA) undergoing immunomodulatory treatments. We designed a retrospective single-center study to investigate their effectiveness and safety in this population, analyzing data from the first vaccination program (December 2020-October 2021). Inclusion criteria were availability of post-vaccination serology and a minimum subsequent follow-up of 6 months. Binding antibody units (BAU/mL) ≥ 7.1 defined an adequate serological response. Post-vaccine COVID-19 incidence and its timing since vaccination, adverse events (AEs), and RA flares were recorded. Adjusted logistic and linear multivariate regression analyses were carried out to identify factors associated with vaccine response. We included 118 patients (87.2% women, age 65.4 ± 11.6 years, evolution 12.0 ± 9.6 years), of whom 95.8% had a complete vaccination schedule. Adequate humoral immunogenicity was achieved in 88.1% of patients and was associated with previous COVID-19 and mRNA vaccines, whereas smoking, aCCP, age, and DMARDs exerted a negative impact. Post-vaccine COVID-19 occurred in 18.6% of patients, a median of 6.5 months after vaccination. Vaccine AE (19.5%) and RA flares (1.7%) were mostly mild and inversely associated with age. Our results suggest that COVID-19 vaccines induce adequate humoral immunogenicity, with an acceptable safety profile in RA patients.
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Affiliation(s)
- María Torres-Rufas
- Hospital Universitario de La Princesa, Calle Diego de León 62, 28006 Madrid, Spain;
| | - Esther F. Vicente-Rabaneda
- Rheumatology Department, Instituto de Investigación Sanitaria de La Princesa (IIS-Princesa), Hospital Universitario de La Princesa, Calle Diego de León 62, 28006 Madrid, Spain; (C.V.-M.); (R.G.-V.); (I.G.-Á.)
| | - Laura Cardeñoso
- Microbiology Department, IIS-Princesa, Hospital Universitario de La Princesa, Calle Diego de León 62, 28006 Madrid, Spain; (L.C.); (A.G.)
| | - Ainhoa Gutierrez
- Microbiology Department, IIS-Princesa, Hospital Universitario de La Princesa, Calle Diego de León 62, 28006 Madrid, Spain; (L.C.); (A.G.)
| | - David A. Bong
- Instituto Poal de Reumatología, Carrer de Castanyer, 15, Sarrià-Sant Gervasi, 08022 Barcelona, Spain;
- Bellvitge Campus, Universitat de Barcelona, Carrer de la Feixa Llarga, s/n, L’Hospitalet de Llobregat, 08907 Barcelona, Spain
| | - Cristina Valero-Martínez
- Rheumatology Department, Instituto de Investigación Sanitaria de La Princesa (IIS-Princesa), Hospital Universitario de La Princesa, Calle Diego de León 62, 28006 Madrid, Spain; (C.V.-M.); (R.G.-V.); (I.G.-Á.)
| | - José M. Serra López-Matencio
- Hospital Pharmacy Department, Hospital Universitario de La Princesa, Calle Diego de León 62, 28006 Madrid, Spain;
| | - Rosario García-Vicuña
- Rheumatology Department, Instituto de Investigación Sanitaria de La Princesa (IIS-Princesa), Hospital Universitario de La Princesa, Calle Diego de León 62, 28006 Madrid, Spain; (C.V.-M.); (R.G.-V.); (I.G.-Á.)
| | - Miguel A. González-Gay
- Rheumatology Department, IIS-Fundación Jiménez Díaz, Hospital Universitario Fundación Jiménez Díaz, Avenida de los Reyes Católicos, 2, Moncloa-Aravaca, 28040 Madrid, Spain;
- Medicine and Psychiatry Department, University of Cantabria, 39008 Santander, Spain
| | - Isidoro González-Álvaro
- Rheumatology Department, Instituto de Investigación Sanitaria de La Princesa (IIS-Princesa), Hospital Universitario de La Princesa, Calle Diego de León 62, 28006 Madrid, Spain; (C.V.-M.); (R.G.-V.); (I.G.-Á.)
| | - Santos Castañeda
- Rheumatology Department, Instituto de Investigación Sanitaria de La Princesa (IIS-Princesa), Hospital Universitario de La Princesa, Calle Diego de León 62, 28006 Madrid, Spain; (C.V.-M.); (R.G.-V.); (I.G.-Á.)
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3
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Eviatar T, Furer V, Polachek A, Zisman D, Peleg H, Elalouf O, Levartovsky D, Kaufman I, Broyde A, Haddad A, Feld J, Aassi M, Quebe-Fehling E, Alarcon I, Pel S, Paran D, Elkayam O. Effect of Secukinumab and Tumor Necrosis Factor Inhibitors on Humoral Response to BNT162b2 mRNA Vaccine in Patients With Spondyloarthritis Compared to Immunocompetent Controls. J Rheumatol 2024; 51:415-422. [PMID: 37914221 DOI: 10.3899/jrheum.2023-0357] [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] [Accepted: 10/06/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVE To assess the humoral response to the BNT162b2 mRNA vaccine among patients with spondyloarthritis (SpA) receiving secukinumab (SEC) compared to those receiving tumor necrosis factor inhibitors (TNFi) and immunocompetent controls. METHODS Consecutive patients with psoriatic arthritis or axial SpA receiving SEC (n = 37) or TNFi (monotherapy, n = 109; + methotrexate [MTX], n = 16), immunocompetent controls (n = 122), and patients with rheumatoid arthritis (RA) receiving TNFi therapy (controls, n = 50) were vaccinated with 2 or 3 doses of the BNT162b2 vaccine. We evaluated humoral response, adverse events, and disease activity, and monitored for breakthrough coronavirus disease 2019 (COVID-19) postvaccination. RESULTS The 2-dose vaccine regimen induced a comparable seropositive response in all study groups. S1/S2 antibody titers (in binding antibody units/mL; mean [SD]) were higher in the SEC group vs the TNFi + MTX-SpA and TNFi-RA groups (192.5 [68.4] vs 104.6 [46.9], P < 0.001, and 143.1 [81.9], P = 0.004). After 6 months, 96.3%, 96.6%, and 80.9% of the SEC, immunocompetent, and TNFi monotherapy-SpA groups (P = 0.10), respectively; 66.7% of the TNFi + MTX-SpA group (P = 0.03); and 63% of the TNFi-RA group (P = 0.004) remained seropositive. S1/S2 antibody titer decline was steeper in the TNFi groups than the SEC group. After the third dose, 100% of the SpA and immunocompetent and 88.9% of the TNFi-RA (P = 0.25) groups were seropositive. Rate of breakthrough COVID-19 infection was higher in the TNFi groups than in the SEC group (36-37.5% vs 10.8%). No significant between-group differences were observed for postvaccination disease activity and adverse events. CONCLUSION SEC did not interfere with the immunogenic response to BNT162b2 vaccine in patients with SpA; however, TNFi therapy was associated with lower S1/S2-antibody titers, faster decline, and higher rate of breakthrough infections.
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Affiliation(s)
- Tali Eviatar
- T. Eviatar, MD, V. Furer, MD, A. Polachek, MD, O. Elalouf, MD, D. Levartovsky, MD, I. Kaufman, MD, A. Broyde, MD, S. Pel, MPH, D. Paran, MD, O. Elkayam, MD, Rheumatology Department, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel;
| | - Victoria Furer
- T. Eviatar, MD, V. Furer, MD, A. Polachek, MD, O. Elalouf, MD, D. Levartovsky, MD, I. Kaufman, MD, A. Broyde, MD, S. Pel, MPH, D. Paran, MD, O. Elkayam, MD, Rheumatology Department, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ari Polachek
- T. Eviatar, MD, V. Furer, MD, A. Polachek, MD, O. Elalouf, MD, D. Levartovsky, MD, I. Kaufman, MD, A. Broyde, MD, S. Pel, MPH, D. Paran, MD, O. Elkayam, MD, Rheumatology Department, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Devy Zisman
- D. Zisman, MD, A. Haddad, MD, J. Feld, MD, Rheumatology Unit, Carmel Hospital, and Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Hagit Peleg
- H. Peleg, MD, Rheumatology Unit, Hadassah University Hospital, and the Hebrew University of Jerusalem Faculty of Medicine, Jerusalem, Jerusalem, Israel
| | - Ofir Elalouf
- T. Eviatar, MD, V. Furer, MD, A. Polachek, MD, O. Elalouf, MD, D. Levartovsky, MD, I. Kaufman, MD, A. Broyde, MD, S. Pel, MPH, D. Paran, MD, O. Elkayam, MD, Rheumatology Department, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Levartovsky
- T. Eviatar, MD, V. Furer, MD, A. Polachek, MD, O. Elalouf, MD, D. Levartovsky, MD, I. Kaufman, MD, A. Broyde, MD, S. Pel, MPH, D. Paran, MD, O. Elkayam, MD, Rheumatology Department, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ilana Kaufman
- T. Eviatar, MD, V. Furer, MD, A. Polachek, MD, O. Elalouf, MD, D. Levartovsky, MD, I. Kaufman, MD, A. Broyde, MD, S. Pel, MPH, D. Paran, MD, O. Elkayam, MD, Rheumatology Department, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Adi Broyde
- T. Eviatar, MD, V. Furer, MD, A. Polachek, MD, O. Elalouf, MD, D. Levartovsky, MD, I. Kaufman, MD, A. Broyde, MD, S. Pel, MPH, D. Paran, MD, O. Elkayam, MD, Rheumatology Department, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir Haddad
- D. Zisman, MD, A. Haddad, MD, J. Feld, MD, Rheumatology Unit, Carmel Hospital, and Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Joy Feld
- D. Zisman, MD, A. Haddad, MD, J. Feld, MD, Rheumatology Unit, Carmel Hospital, and Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Maher Aassi
- M. Aassi, MD, E. Quebe-Fehling, PhD, I. Alarcon, MD, Novartis Pharma AG, Medical Affairs, Basel, Switzerland
| | - Erhard Quebe-Fehling
- M. Aassi, MD, E. Quebe-Fehling, PhD, I. Alarcon, MD, Novartis Pharma AG, Medical Affairs, Basel, Switzerland
| | - Ivette Alarcon
- M. Aassi, MD, E. Quebe-Fehling, PhD, I. Alarcon, MD, Novartis Pharma AG, Medical Affairs, Basel, Switzerland
| | - Sara Pel
- T. Eviatar, MD, V. Furer, MD, A. Polachek, MD, O. Elalouf, MD, D. Levartovsky, MD, I. Kaufman, MD, A. Broyde, MD, S. Pel, MPH, D. Paran, MD, O. Elkayam, MD, Rheumatology Department, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daphna Paran
- T. Eviatar, MD, V. Furer, MD, A. Polachek, MD, O. Elalouf, MD, D. Levartovsky, MD, I. Kaufman, MD, A. Broyde, MD, S. Pel, MPH, D. Paran, MD, O. Elkayam, MD, Rheumatology Department, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ori Elkayam
- T. Eviatar, MD, V. Furer, MD, A. Polachek, MD, O. Elalouf, MD, D. Levartovsky, MD, I. Kaufman, MD, A. Broyde, MD, S. Pel, MPH, D. Paran, MD, O. Elkayam, MD, Rheumatology Department, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Tsuzuki Wada T, Yokota K, Inayoshi F, Sakai S, Okumura N, Matsuda M, Osawa I, Araki Y, Funakubo Asanuma Y, Akiyama Y, Mimura T. New-onset Immune-mediated Necrotizing Myopathy and Trigeminal Neuropathy after SARS-CoV-2 mRNA Vaccination in a Patient with Rheumatoid Arthritis and Sjögren's Syndrome. Intern Med 2023; 62:3699-3706. [PMID: 37839879 PMCID: PMC10781545 DOI: 10.2169/internalmedicine.2551-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 08/30/2023] [Indexed: 10/17/2023] Open
Abstract
We present the case of a 42-year-old woman with rheumatoid arthritis and Sjögren's syndrome treated with adalimumab who developed immune-mediated necrotizing myopathy (IMNM) and trigeminal neuropathy after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) mRNA vaccination. Trigeminal neuralgia and elevated serum creatine kinase levels emerged 12 days post-vaccination, followed by myalgia in the femoral muscles. IMNM was histologically diagnosed. The pathogenesis may involve molecular mimicry between the SARS-CoV-2 spike glycoprotein and autologous tissues triggered by vaccination. This case emphasizes the association between SARS-CoV-2 vaccination, tumor necrosis factor inhibitor, IMNM, and trigeminal neuropathy, as well as the importance of monitoring immune-mediated adverse events following SARS-CoV-2 vaccination in patients with autoimmune disease.
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Affiliation(s)
- Takuma Tsuzuki Wada
- Department of Rheumatology and Applied Immunology, Faculty of Medicine, Saitama Medical University, Japan
| | - Kazuhiro Yokota
- Department of Rheumatology and Applied Immunology, Faculty of Medicine, Saitama Medical University, Japan
| | - Fumito Inayoshi
- Department of Rheumatology and Applied Immunology, Faculty of Medicine, Saitama Medical University, Japan
| | - Sakon Sakai
- Department of Rheumatology and Applied Immunology, Faculty of Medicine, Saitama Medical University, Japan
| | - Nobuhito Okumura
- Department of Rheumatology and Applied Immunology, Faculty of Medicine, Saitama Medical University, Japan
| | - Mayumi Matsuda
- Department of Rheumatology and Applied Immunology, Faculty of Medicine, Saitama Medical University, Japan
| | - Iichiro Osawa
- Department of Radiology, Saitama Medical University Hospital, Japan
| | - Yasuto Araki
- Department of Rheumatology and Applied Immunology, Faculty of Medicine, Saitama Medical University, Japan
| | - Yu Funakubo Asanuma
- Department of Rheumatology and Applied Immunology, Faculty of Medicine, Saitama Medical University, Japan
| | - Yuji Akiyama
- Department of Rheumatology and Applied Immunology, Faculty of Medicine, Saitama Medical University, Japan
| | - Toshihide Mimura
- Department of Rheumatology and Applied Immunology, Faculty of Medicine, Saitama Medical University, Japan
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Widhani A, Hasibuan AS, Rismawati R, Maria S, Koesnoe S, Hermanadi MI, Ophinni Y, Yamada C, Harimurti K, Sari ANL, Yunihastuti E, Djauzi S. Efficacy, Immunogenicity, and Safety of COVID-19 Vaccines in Patients with Autoimmune Diseases: A Systematic Review and Meta-Analysis. Vaccines (Basel) 2023; 11:1456. [PMID: 37766132 PMCID: PMC10535431 DOI: 10.3390/vaccines11091456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 08/30/2023] [Accepted: 09/01/2023] [Indexed: 09/29/2023] Open
Abstract
Patients with autoimmune diseases are among the susceptible groups to COVID-19 infection because of the complexity of their conditions and the side effects of the immunosuppressive drugs used to treat them. They might show impaired immunogenicity to COVID-19 vaccines and have a higher risk of developing COVID-19. Using a systematic review and meta-analysis, this research sought to summarize the evidence on COVID-19 vaccine efficacy, immunogenicity, and safety in patients with autoimmune diseases following predefined eligibility criteria. Research articles were obtained from an initial search up to 26 September 2022 from PubMed, Embase, EBSCOhost, ProQuest, MedRxiv, bioRxiv, SSRN, EuroPMC, and the Cochrane Center of Randomized Controlled Trials (CCRCT). Of 76 eligible studies obtained, 29, 54, and 38 studies were included in systematic reviews of efficacy, immunogenicity, and safety, respectively, and 6, 18, and 4 studies were included in meta-analyses for efficacy, immunogenicity, and safety, respectively. From the meta-analyses, patients with autoimmune diseases showed more frequent breakthrough COVID-19 infections and lower total antibody (TAb) titers, IgG seroconversion, and neutralizing antibodies after inactivated COVID-19 vaccination compared with healthy controls. They also had more local and systemic adverse events after the first dose of inactivated vaccination compared with healthy controls. After COVID-19 mRNA vaccination, patients with autoimmune diseases had lower TAb titers and IgG seroconversion compared with healthy controls.
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Affiliation(s)
- Alvina Widhani
- Allergy and Clinical Immunology Division, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta 10430, Indonesia; (A.S.H.); (R.R.); (S.M.); (S.K.); (M.I.H.); (A.N.L.S.); (E.Y.); (S.D.)
- Department of Internal Medicine, Universitas Indonesia Hospital, Depok 16424, Indonesia
| | - Anshari Saifuddin Hasibuan
- Allergy and Clinical Immunology Division, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta 10430, Indonesia; (A.S.H.); (R.R.); (S.M.); (S.K.); (M.I.H.); (A.N.L.S.); (E.Y.); (S.D.)
| | - Retia Rismawati
- Allergy and Clinical Immunology Division, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta 10430, Indonesia; (A.S.H.); (R.R.); (S.M.); (S.K.); (M.I.H.); (A.N.L.S.); (E.Y.); (S.D.)
| | - Suzy Maria
- Allergy and Clinical Immunology Division, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta 10430, Indonesia; (A.S.H.); (R.R.); (S.M.); (S.K.); (M.I.H.); (A.N.L.S.); (E.Y.); (S.D.)
| | - Sukamto Koesnoe
- Allergy and Clinical Immunology Division, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta 10430, Indonesia; (A.S.H.); (R.R.); (S.M.); (S.K.); (M.I.H.); (A.N.L.S.); (E.Y.); (S.D.)
| | - Muhammad Ikrar Hermanadi
- Allergy and Clinical Immunology Division, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta 10430, Indonesia; (A.S.H.); (R.R.); (S.M.); (S.K.); (M.I.H.); (A.N.L.S.); (E.Y.); (S.D.)
| | - Youdiil Ophinni
- Division of Clinical Virology, Center for Infectious Diseases, Graduate School of Medicine, Kobe University, Kobe 650-0017, Japan;
- Department of Host Defense, Immunology Frontier Research Center, Osaka University, Osaka 565-0871, Japan
- Center for Southeast Asian Studies, Kyoto University, Kyoto 606-8304, Japan;
| | - Chika Yamada
- Center for Southeast Asian Studies, Kyoto University, Kyoto 606-8304, Japan;
| | - Kuntjoro Harimurti
- Geriatric Division, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta 10430, Indonesia;
| | - Aldean Nadhyia Laela Sari
- Allergy and Clinical Immunology Division, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta 10430, Indonesia; (A.S.H.); (R.R.); (S.M.); (S.K.); (M.I.H.); (A.N.L.S.); (E.Y.); (S.D.)
| | - Evy Yunihastuti
- Allergy and Clinical Immunology Division, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta 10430, Indonesia; (A.S.H.); (R.R.); (S.M.); (S.K.); (M.I.H.); (A.N.L.S.); (E.Y.); (S.D.)
| | - Samsuridjal Djauzi
- Allergy and Clinical Immunology Division, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta 10430, Indonesia; (A.S.H.); (R.R.); (S.M.); (S.K.); (M.I.H.); (A.N.L.S.); (E.Y.); (S.D.)
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6
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van Sleen Y, van der Geest KSM, Huckriede ALW, van Baarle D, Brouwer E. Effect of DMARDs on the immunogenicity of vaccines. Nat Rev Rheumatol 2023; 19:560-575. [PMID: 37438402 DOI: 10.1038/s41584-023-00992-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2023] [Indexed: 07/14/2023]
Abstract
Vaccines are important for protecting individuals at increased risk of severe infections, including patients undergoing DMARD therapy. However, DMARD therapy can also compromise the immune system, leading to impaired responses to vaccination. This Review focuses on the impact of DMARDs on influenza and SARS-CoV-2 vaccinations, as such vaccines have been investigated most thoroughly. Various data suggest that B cell depletion therapy, mycophenolate mofetil, cyclophosphamide, azathioprine and abatacept substantially reduce the immunogenicity of these vaccines. However, the effects of glucocorticoids, methotrexate, TNF inhibitors and JAK inhibitors on vaccine responses remain unclear and could depend on the dosage and type of vaccination. Vaccination is aimed at initiating robust humoral and cellular vaccine responses, which requires efficient interactions between antigen-presenting cells, T cells and B cells. DMARDs impair these cells in different ways and to different degrees, such as the prevention of antigen-presenting cell maturation, alteration of T cell differentiation and selective inhibition of B cell subsets, thus inhibiting processes that are necessary for an effective vaccine response. Innovative modified vaccination strategies are needed to improve vaccination responses in patients undergoing DMARD therapy and to protect these patients from the severe outcomes of infectious diseases.
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Affiliation(s)
- Yannick van Sleen
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, the Netherlands.
| | - Kornelis S M van der Geest
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, the Netherlands
| | - Anke L W Huckriede
- Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, Groningen, the Netherlands
| | - Debbie van Baarle
- Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, Groningen, the Netherlands
| | - Elisabeth Brouwer
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, the Netherlands.
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Bae SS, Faure-Kumar E, Ferbas K, Wang J, Shahbazian A, Truong L, Yang H, McMahon M, FitzGerald JD, Charles-Schoeman C. Assessment of antibody levels to SARS-CoV-2 in patients with idiopathic inflammatory myopathies receiving treatment with intravenous immunoglobulin. Rheumatol Int 2023; 43:1629-1636. [PMID: 37368037 PMCID: PMC10348966 DOI: 10.1007/s00296-023-05350-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/23/2023] [Indexed: 06/28/2023]
Abstract
Antibodies to Severe Acute Respiratory Syndrome-Coronavirus 2 (SARS-CoV-2) have been reported in pooled healthy donor plasma and intravenous immunoglobulin products (IVIG). It is not known whether administration of IVIG increases circulating anti-SARS-CoV-2 antibodies (COVID ab) in IVIG recipients. COVID ab against the receptor binding domain of the spike protein were analyzed using a chemiluminescent microparticle immunoassay in patients with idiopathic inflammatory myopathies (IIM) both receiving and not receiving IVIG (IVIG and non-IVIG group, respectively). No significant differences in COVID ab levels were noted between IVIG and non-IVIG groups (417 [67-1342] AU/mL in IVIG vs 5086 [43-40,442] AU/mL in non-IVIG, p = 0.11). In linear regression models including all post-vaccination patient samples, higher number of vaccine doses was strongly associated with higher COVID ab levels (2.85 [1.21, 4.48] log AU/mL, regression coefficient [Formula: see text] [95% CI], p = 0.001), while use of RTX was associated with lower ab levels (2.73 [- 4.53, - 0.93] log AU/mL, [Formula: see text][95%CI], p = 0.004). In the IVIG group, higher total monthly doses of IVIG were associated with slightly higher COVID ab levels (0.02 [0.002-0.05] log AU/mL, p = 0.04). While patients on IVIG did not have higher COVID ab levels compared to the non-IVIG group, higher monthly doses of IVIG were associated with higher circulating levels of COVID ab in patients receiving IVIG, particularly in patients concomitantly receiving RTX. Our findings suggest that IIM patients, especially those at increased risk of COVID infection and worse COVID outcomes due to RTX therapy may have protective benefits when on concurrent IVIG treatment.
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Affiliation(s)
- Sangmee Sharon Bae
- David Geffen School of Medicine, Division of Rheumatology, University of California Los Angeles, Los Angeles, CA, USA.
| | - Emmanuelle Faure-Kumar
- David Geffen School of Medicine, Vatche and Tamar Manoukian Division of Digestive Diseases, University of California Los Angeles, Los Angeles, CA, USA
| | - Kathie Ferbas
- David Geffen School of Medicine, Department of Pediatrics, University of California Los Angeles, Los Angeles, CA, USA
| | - Jennifer Wang
- David Geffen School of Medicine, Division of Rheumatology, University of California Los Angeles, Los Angeles, CA, USA
| | - Ani Shahbazian
- David Geffen School of Medicine, Division of Rheumatology, University of California Los Angeles, Los Angeles, CA, USA
| | - Linh Truong
- David Geffen School of Medicine, Division of Rheumatology, University of California Los Angeles, Los Angeles, CA, USA
| | - Howard Yang
- David Geffen School of Medicine, Division of Rheumatology, University of California Los Angeles, Los Angeles, CA, USA
| | - Maureen McMahon
- David Geffen School of Medicine, Division of Rheumatology, University of California Los Angeles, Los Angeles, CA, USA
| | - John D FitzGerald
- David Geffen School of Medicine, Division of Rheumatology, University of California Los Angeles, Los Angeles, CA, USA
| | - Christina Charles-Schoeman
- David Geffen School of Medicine, Division of Rheumatology, University of California Los Angeles, Los Angeles, CA, USA
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8
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Speer C, Töllner M, Benning L, Bartenschlager M, Kim H, Nusshag C, Kälble F, Reineke M, Reichel P, Schnitzler P, Zeier M, Morath C, Schmitt W, Bergner R, Bartenschlager R, Lorenz HM, Schaier M. BA.1/BA.5 Immunogenicity, Reactogenicity, and Disease Activity after COVID-19 Vaccination in Patients with ANCA-Associated Vasculitis: A Prospective Observational Cohort Study. Viruses 2023; 15:1778. [PMID: 37632120 PMCID: PMC10458303 DOI: 10.3390/v15081778] [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: 07/07/2023] [Revised: 08/13/2023] [Accepted: 08/20/2023] [Indexed: 08/27/2023] Open
Abstract
Emerging omicron subtypes with immune escape lead to inadequate vaccine response with breakthrough infections in immunocompromised individuals such as Anti-neutrophil Cytoplasmic Antibody (ANCA)-associated vasculitis (AAV) patients. As AAV is considered an orphan disease, there are still limited data on SARS-CoV-2 vaccination and prospective studies that have focused exclusively on AAV patients are lacking. In addition, there are safety concerns regarding the use of highly immunogenic mRNA vaccines in autoimmune diseases, and further studies investigating reactogenicity are urgently needed. In this prospective observational cohort study, we performed a detailed characterization of neutralizing antibody responses against omicron subtypes and provided a longitudinal assessment of vaccine reactogenicity and AAV disease activity. Different vaccine doses were generally well tolerated and no AAV relapses occurred during follow-up. AAV patients had significantly lower anti-S1 IgG and surrogate-neutralizing antibodies after first, second, and third vaccine doses as compared to healthy controls, respectively. Live-virus neutralization assays against omicron subtypes BA.1 and BA.5 revealed that previous SARS-CoV-2 vaccines result in an inadequate neutralizing immune response in immunocompromised AAV patients. These data demonstrate that new vaccination strategies including adapted mRNA vaccines against epitopes of emerging variants are needed to help protect highly vulnerable individuals such as AAV patients.
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Affiliation(s)
- Claudius Speer
- Department of Nephrology, University Hospital Heidelberg, 69120 Heidelberg, Germany; (M.T.); (L.B.); (C.N.); (F.K.); (M.R.); (P.R.); (M.Z.); (C.M.); (M.S.)
- Molecular Medicine Partnership Unit Heidelberg, EMBL, 69120 Heidelberg, Germany
| | - Maximilian Töllner
- Department of Nephrology, University Hospital Heidelberg, 69120 Heidelberg, Germany; (M.T.); (L.B.); (C.N.); (F.K.); (M.R.); (P.R.); (M.Z.); (C.M.); (M.S.)
| | - Louise Benning
- Department of Nephrology, University Hospital Heidelberg, 69120 Heidelberg, Germany; (M.T.); (L.B.); (C.N.); (F.K.); (M.R.); (P.R.); (M.Z.); (C.M.); (M.S.)
| | - Marie Bartenschlager
- Department of Infectious Diseases, Molecular Virology, Center for Integrative Infectious Disease Research, Medical Faculty Heidelberg, Heidelberg University, 68167 Heidelberg, Germany; (M.B.); (H.K.); (R.B.)
| | - Heeyoung Kim
- Department of Infectious Diseases, Molecular Virology, Center for Integrative Infectious Disease Research, Medical Faculty Heidelberg, Heidelberg University, 68167 Heidelberg, Germany; (M.B.); (H.K.); (R.B.)
| | - Christian Nusshag
- Department of Nephrology, University Hospital Heidelberg, 69120 Heidelberg, Germany; (M.T.); (L.B.); (C.N.); (F.K.); (M.R.); (P.R.); (M.Z.); (C.M.); (M.S.)
| | - Florian Kälble
- Department of Nephrology, University Hospital Heidelberg, 69120 Heidelberg, Germany; (M.T.); (L.B.); (C.N.); (F.K.); (M.R.); (P.R.); (M.Z.); (C.M.); (M.S.)
| | - Marvin Reineke
- Department of Nephrology, University Hospital Heidelberg, 69120 Heidelberg, Germany; (M.T.); (L.B.); (C.N.); (F.K.); (M.R.); (P.R.); (M.Z.); (C.M.); (M.S.)
| | - Paula Reichel
- Department of Nephrology, University Hospital Heidelberg, 69120 Heidelberg, Germany; (M.T.); (L.B.); (C.N.); (F.K.); (M.R.); (P.R.); (M.Z.); (C.M.); (M.S.)
| | - Paul Schnitzler
- Department of Infectious Diseases, Virology, University Hospital Heidelberg, 69120 Heidelberg, Germany;
| | - Martin Zeier
- Department of Nephrology, University Hospital Heidelberg, 69120 Heidelberg, Germany; (M.T.); (L.B.); (C.N.); (F.K.); (M.R.); (P.R.); (M.Z.); (C.M.); (M.S.)
| | - Christian Morath
- Department of Nephrology, University Hospital Heidelberg, 69120 Heidelberg, Germany; (M.T.); (L.B.); (C.N.); (F.K.); (M.R.); (P.R.); (M.Z.); (C.M.); (M.S.)
| | | | - Raoul Bergner
- Department of Internal Medicine A, Clinical Center Ludwigshafen, 67071 Ludwigshafen, Germany;
| | - Ralf Bartenschlager
- Department of Infectious Diseases, Molecular Virology, Center for Integrative Infectious Disease Research, Medical Faculty Heidelberg, Heidelberg University, 68167 Heidelberg, Germany; (M.B.); (H.K.); (R.B.)
- German Center for Infection Research (DZIF), Heidelberg Partner Site, 69120 Heidelberg, Germany
- Division Virus-Associated Carcinogenesis, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Hanns-Martin Lorenz
- Division of Rheumatology, Department of Medicine V, University of Heidelberg, 69120 Heidelberg, Germany;
| | - Matthias Schaier
- Department of Nephrology, University Hospital Heidelberg, 69120 Heidelberg, Germany; (M.T.); (L.B.); (C.N.); (F.K.); (M.R.); (P.R.); (M.Z.); (C.M.); (M.S.)
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9
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Zamani B, Moradi Hasan-Abad A, Piroozmand A, Dehghani M, Arfaatabar M, Motedayyen H. Immunogenicity and safety of the BBIBP-CorV vaccine in patients with autoimmune inflammatory rheumatic diseases undergoing immunosuppressive therapy in a monocentric cohort. Immun Inflamm Dis 2023; 11:e858. [PMID: 37249277 DOI: 10.1002/iid3.858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 03/24/2023] [Accepted: 04/21/2023] [Indexed: 05/31/2023] Open
Abstract
INTRODUCTION Vaccination plays a fundamental role in mastering the COVID-19 pandemic and protecting vulnerable groups. Persons with autoimmune inflammatory rheumatic diseases (AIIRD) requiring immunosuppressive therapies are prioritized for vaccination. However, data concerning immunogenicity and safety of the BBIBP-CorV vaccine in immunosuppressed patients are not found. This study presents data on the efficacy and safety of the BBIBP-CorV vaccine in immunosuppressed patients compared to healthy controls. METHODS Study population consisted of 100 healthy controls and 100 patients with AIIRD. Vaccination was performed according to national guidelines with the BBIBP-CorV vaccine. SARS-CoV-2 neutralizing antibody titers were quantified by enzyme-linked immunosorbent assay before initial vaccination and 1-3 months after secondary vaccination. Adverse events were assessed before study initiation and 7 days after the second dose. Disease activity was studied before entering the study and 3-8 weeks after the second dose. RESULTS Vaccination-induced positive immunogenic response rates and SARS-CoV-2 neutralizing antibody titers were significantly lower in the AIIRD patients than healthy subjects (p < .05). There are significant differences in neutralizing antibody titers among patients suffering from rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), systemic sclerosis, and ankylosing spondylitis (p < .01-.05). The rates of seropositive vaccine responses were similarly distributed across all diseases. Healthy and AIIRD individuals had a similar profile in adverse events. No significant difference was observed in SARS-CoV-2 antibody titers between subjects suffering from side effects and those who did not have. SARS-CoV-2 neutralizing antibody levels were significantly higher in subjects with a history of COVID-19 infection than seronegative individuals (p < .01-0.05). Seropositive subjects had a significant increase in the percentage of vaccine-related adverse events compared to seronegative persons (p < .05). Despite a minor change in the disease activity of patients with RA and SLE, disease activity indices were overall stable in the AIIRD patients. CONCLUSION These findings revealed that the BBIBP-CorV vaccine is effective in the development of neutralizing antibodies in immunosuppressed patients without considerable reactogenicity or induction of disease flares.
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Affiliation(s)
- Batool Zamani
- Autoimmune Diseases Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Amin Moradi Hasan-Abad
- Autoimmune Diseases Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Ahmad Piroozmand
- Autoimmune Diseases Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Mahsa Dehghani
- Autoimmune Diseases Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Maryam Arfaatabar
- Department of Medical Laboratory Sciences, Kashan Branch, Islamic Azad University, Kashan, Iran
| | - Hossein Motedayyen
- Autoimmune Diseases Research Center, Kashan University of Medical Sciences, Kashan, Iran
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10
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Deguchi H, Sakamoto A, Nakamura N, Okabe Y, Miura Y, Iida T, Yoshimura M, Haga N, Nabeshima S, Masutani K. Antibody acquisition after second and third SARS-CoV-2 vaccinations in Japanese kidney transplant patients: a prospective study. Clin Exp Nephrol 2023; 27:574-582. [PMID: 36914824 PMCID: PMC10010649 DOI: 10.1007/s10157-023-02334-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 02/27/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND Kidney transplant patients have lower antibody acquisition after SARS-CoV-2 vaccination. The efficacy of vaccines in Japanese kidney transplant patients with specific characteristics, such as predominant living-donor, ABO-incompatible kidney transplant, and low-dose immunosuppression, requires verification. METHODS We conducted a prospective study to estimate anti-SARS-CoV-2 antibody levels in 105 kidney transplant patients and 57 controls. Blood samples were obtained before vaccination, 1, 3, and 6 months after second vaccination, and 1 month after third vaccination. We investigated antibody acquisition rates, antibody levels, and factors associated with antibody acquisition. RESULTS One month after second vaccination, antibody acquisition was 100% in the controls but only 36.7% in the kidney transplant group (P < 0.001). Antibody levels in positive kidney transplant patients were also lower than in the controls (median, 4.9 arbitrary units vs 106.4 arbitrary units, respectively, P < 0.001). Years after kidney transplant (odds ratio 1.107, 95% confidence interval 1.012-1.211), ABO-incompatible kidney transplant (odds ratio 0.316, 95% confidence interval 0.101-0.991) and mycophenolate mofetil use (odds ratio 0.177, 95% confidence interval 0.054-0.570) were significant predictors for antibody acquisition after second vaccination. After third vaccination, antibody positivity in the kidney transplant group increased to 75.3%, and antibody levels in positive patients were 71.7 arbitrary units. No factors were associated with de novo antibody acquisition. CONCLUSIONS In Japanese kidney transplant patients, years after kidney transplant, ABO-incompatible kidney transplant and mycophenolate mofetil use were predictors for antibody acquisition after second vaccination. Third vaccination improves antibody status even in patients who were seronegative after the second vaccination.
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Affiliation(s)
- Hidetaka Deguchi
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-Ku, Fukuoka, 814-0180, Japan
| | - Atsuhiko Sakamoto
- Department of General Medicine, Fukuoka University Hospital, Fukuoka, Japan
| | - Nobuyuki Nakamura
- Department of Urology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Yasuhiro Okabe
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshifumi Miura
- Department of General Surgery, Hara-Sanshin Hospital, Fukuoka, Japan
| | | | - Michinobu Yoshimura
- Department of Microbiology and Immunology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Nobuhiro Haga
- Department of Urology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Shigeki Nabeshima
- Department of General Medicine, Fukuoka University Hospital, Fukuoka, Japan
| | - Kosuke Masutani
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-Ku, Fukuoka, 814-0180, Japan.
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11
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Md Yusof MY, Arnold J, Saleem B, Vandevelde C, Dass S, Savic S, Vital EM, Emery P. Breakthrough SARS-CoV-2 infections and prediction of moderate-to-severe outcomes during rituximab therapy in patients with rheumatic and musculoskeletal diseases in the UK: a single-centre cohort study. THE LANCET. RHEUMATOLOGY 2023; 5:e88-e98. [PMID: 36712951 PMCID: PMC9873269 DOI: 10.1016/s2665-9913(23)00004-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background Concerns have been raised regarding the reduced immunogenicity of vaccines against COVID-19 in patients with autoimmune diseases treated with rituximab. However, the incidence and severity of breakthrough infections in unbiased samples of patients with specific rheumatic and musculoskeletal diseases are largely unknown. We aimed to assess the incidence of breakthrough SARS-CoV-2 infection, compare rates of moderate-to-severe COVID-19 with any severe infection event, and evaluate predictors of moderate-to-severe COVID-19 outcomes in patients treated with rituximab. Methods We did a retrospective cohort study in all rituximab-treated patients with rheumatic and musculoskeletal diseases in a single centre in Leeds, UK between March 1, 2020 (the index date), and April 1, 2022. Adults aged 18 years and older, who fulfilled classification criteria for established rheumatic and musculoskeletal diseases, and received therapy with at least one rituximab infusion between Sept 1, 2019 (6 months before the pandemic in the UK), and April 1, 2022, were eligible for inclusion in the study. SARS-CoV-2 infection was defined by antigen test or PCR. COVID-19 outcomes were categorised as mild (from ambulatory to hospitalised but not requiring oxygen support) or moderate-to-severe (hospitalised and requiring oxygen support or death). The primary outcome was breakthrough COVID-19 infection, which was defined as an infection occurring 14 days or more after the second vaccine dose. Predictors of moderate-to-severe COVID-19 outcomes were analysed using Cox regression proportional hazards. Findings Of the 1280 patients who were treated with at least one cycle of rituximab since Jan 1, 2002, 485 (38%) remained on rituximab therapy on April 1, 2022. Of these patients, 400 fulfilled all inclusion criteria and were included in our final analysis. The mean age at the index date was 58·9 years (SD 14·6), 288 (72%) of 400 patients were female and 112 (28%) were male, 333 (83%) were White, and 110 (28%) had two or more comorbidities. 272 (68%) of 400 patients had rheumatoid arthritis, 48 (12%) had systemic lupus erythematosus, 48 (12%) had anti-neutrophil cytoplasmic antibody-associated vasculitis, and 46 (12%) had other rheumatic and musculoskeletal diseases. During the study, 798 rituximab cycles were administered. Of the 398 (>99%) of 400 patients with vaccine data, 372 (93%) were fully vaccinated. Over the 774·6 patient-years of follow-up, there was an incremental increase in all SARS-CoV-2 severity types over the three pandemic phases (wild-type or alpha, delta, and omicron), but most infections were mild. The rates of moderate-to-severe COVID-19 were broadly similar across these three variant phases. Of 370 patients who were fully vaccinated and with complete data, 110 (30%) had all severity type breakthrough COVID-19, 16 (4%) had moderate-to-severe breakthrough COVID-19, and one (<1%) died. In the post-vaccination phase (after Dec 18, 2020), the incidence rates of all severity type and moderate-to-severe COVID-19 were substantially lower in those who were fully vaccinated compared with unvaccinated or partially vaccinated individuals (22·83 per 100 person-years [95% CI 18·94-27·52] in those who were fully vaccinated vs 89·46 per 100 person-years [52·98-151·05] in those who were partially vaccinated or unvaccinated for infections of all severities, and 3·32 per 100 person-years [2·03-5·42] in those who were fully vaccinated vs 25·56 per 100 person-years [9·59-68·10] in those who were partially vaccinated or unvaccinated for moderate-to-severe infections). The rate of moderate-to-severe COVID-19 was broadly similar to other severe infection events in this cohort (5·68 per 100 person-years [95% CI 4·22-7·63]). In multivariable Cox regression analysis, factors associated with an increased risk of moderate-to-severe COVID-19 were the number of comorbidities (hazard ratio 1·46 [95% CI 1·13-1·89]; p=0·0037) and hypogammaglobulinaemia (defined by a pre-rituximab IgG concentration of <6 g/L; 3·22 [1·27-8·19]; p=0·014). This risk was reduced with each vaccine dose received (0·49 [0·37-0·65]; p<0·0001). Other factors, including concomitant prednisolone use, rituximab-associated factors (eg, rituximab dose and time to vaccination since last rituximab dose), and vaccine-associated factors (eg, vaccine type and peripheral B-cell depletion) were not predictive of moderate-to-severe COVID-19 outcomes. Interpretation This study presented detailed analyses of rituximab-treated patients during various phases of the COVID-19 pandemic. In later stages of the pandemic, the SARS-CoV-2 breakthrough infection rate was high but severe COVID-19 rates were similar to any severe infection event rate in patients who were vaccinated. The risk-benefit ratio might still favour rituximab in vaccinated patients with severe rheumatic and musculoskeletal diseases who have few other treatment options. Increased vigilance is needed in the presence of comorbidities and hypogammaglobulinaemia for all infection types. Funding Wellcome Trust and Eli Lilly.
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Affiliation(s)
- Md Yuzaiful Md Yusof
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jack Arnold
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
| | - Benazir Saleem
- Rheumatology Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Claire Vandevelde
- Rheumatology Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Shouvik Dass
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Rheumatology Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sinisa Savic
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Edward M Vital
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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12
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Egri N, Calderón H, Martinez R, Vazquez M, Gómez-Caverzaschi V, Pascal M, Araújo O, Juan M, González-Navarro EA, Hernández-Rodríguez J. Cellular and humoral responses after second and third SARS-CoV-2 vaccinations in patients with autoimmune diseases treated with rituximab: specific T cell immunity remains longer and plays a protective role against SARS-CoV-2 reinfections. Front Immunol 2023; 14:1146841. [PMID: 37180097 PMCID: PMC10174323 DOI: 10.3389/fimmu.2023.1146841] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 04/07/2023] [Indexed: 05/15/2023] Open
Abstract
Background Humoral and cellular immune responses are known to be crucial for patients to recover from COVID-19 and to protect them against SARS-CoV-2 reinfection once infected or vaccinated. Objectives This study aimed to investigate humoral and T cell responses to SARS-CoV-2 vaccination in patients with autoimmune diseases after the second and third vaccine doses while on rituximab and their potential protective role against reinfection. Methods Ten COVID-19-naïve patients were included. Three time points were used for monitoring cellular and humoral responses: pre-vaccine to exclude virus exposure (time point 1) and post-second and post-third vaccine (time points 2 and 3). Specific IgG antibodies were monitored by Luminex and T cells against SARS-CoV-2 spike-protein by ELISpot and CoVITEST. All episodes of symptomatic COVID-19 were recorded. Results Nine patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis and one with an undifferentiated autoimmune disease were included. Nine patients received mRNA vaccines. The last rituximab infusion was administered for a mean (SD) of 15 (10) weeks before the first vaccine and six patients were CD19-B cell-depleted. After a mean (SD) of 19 (10) and 16 (2) days from the second and third vaccine dose, IgG anti-SARS-CoV-2 antibodies were detected in six (60%) and eight (80%) patients, respectively. All patients developed specific T cell responses by ELISpot and CoVITEST in time points 2 and 3. Previous B cell depletion correlated with anti-SARS-CoV-2 IgG levels. Nine (90%) patients developed mild COVID-19 after a median of 7 months of the third dose. Conclusion Rituximab in patients with autoimmune diseases reduces humoral responses but does not avoid the development of T cell responses to SARS-CoV-2 vaccination, which remain present after a booster dose. A steady cellular immunity appears to be protective against subsequent reinfections.
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Affiliation(s)
- Natalia Egri
- Department of Immunology, Centre de Diagnòstic Biomèdic, Hospital Clínic of Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) and ERN on Connective Tissue and Musculoskeletal Diseases (ReCONNET); Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d’Unitats d’Expertesa Clínica (XUEC) for Autoinflammatory Diseases, Autoimmune Diseases and Primary Immunodeficiencies, Barcelona, Spain
| | - Hugo Calderón
- Department of Immunology, Centre de Diagnòstic Biomèdic, Hospital Clínic of Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) and ERN on Connective Tissue and Musculoskeletal Diseases (ReCONNET); Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d’Unitats d’Expertesa Clínica (XUEC) for Autoinflammatory Diseases, Autoimmune Diseases and Primary Immunodeficiencies, Barcelona, Spain
| | - Robert Martinez
- Department of Immunology, Centre de Diagnòstic Biomèdic, Hospital Clínic of Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) and ERN on Connective Tissue and Musculoskeletal Diseases (ReCONNET); Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d’Unitats d’Expertesa Clínica (XUEC) for Autoinflammatory Diseases, Autoimmune Diseases and Primary Immunodeficiencies, Barcelona, Spain
| | - Mario Vazquez
- Department of Immunology, Centre de Diagnòstic Biomèdic, Hospital Clínic of Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) and ERN on Connective Tissue and Musculoskeletal Diseases (ReCONNET); Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d’Unitats d’Expertesa Clínica (XUEC) for Autoinflammatory Diseases, Autoimmune Diseases and Primary Immunodeficiencies, Barcelona, Spain
| | - Verónica Gómez-Caverzaschi
- Clinical Unit of Autoinflammatory Diseases and Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clínic of Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) and ERN on Connective Tissue and Musculoskeletal Diseases (ReCONNET), Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d’Unitats d’Expertesa Clínica (XUEC) for Autoinflammatory Diseases, Autoimmune Diseases and Primary Immunodeficiencies, Barcelona, Spain
| | - Mariona Pascal
- Department of Immunology, Centre de Diagnòstic Biomèdic, Hospital Clínic of Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) and ERN on Connective Tissue and Musculoskeletal Diseases (ReCONNET); Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d’Unitats d’Expertesa Clínica (XUEC) for Autoinflammatory Diseases, Autoimmune Diseases and Primary Immunodeficiencies, Barcelona, Spain
| | - Olga Araújo
- Clinical Unit of Autoinflammatory Diseases and Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clínic of Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) and ERN on Connective Tissue and Musculoskeletal Diseases (ReCONNET), Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d’Unitats d’Expertesa Clínica (XUEC) for Autoinflammatory Diseases, Autoimmune Diseases and Primary Immunodeficiencies, Barcelona, Spain
| | - Manel Juan
- Department of Immunology, Centre de Diagnòstic Biomèdic, Hospital Clínic of Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) and ERN on Connective Tissue and Musculoskeletal Diseases (ReCONNET); Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d’Unitats d’Expertesa Clínica (XUEC) for Autoinflammatory Diseases, Autoimmune Diseases and Primary Immunodeficiencies, Barcelona, Spain
| | - Europa Azucena González-Navarro
- Department of Immunology, Centre de Diagnòstic Biomèdic, Hospital Clínic of Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) and ERN on Connective Tissue and Musculoskeletal Diseases (ReCONNET); Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d’Unitats d’Expertesa Clínica (XUEC) for Autoinflammatory Diseases, Autoimmune Diseases and Primary Immunodeficiencies, Barcelona, Spain
| | - José Hernández-Rodríguez
- Clinical Unit of Autoinflammatory Diseases and Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clínic of Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) and ERN on Connective Tissue and Musculoskeletal Diseases (ReCONNET), Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d’Unitats d’Expertesa Clínica (XUEC) for Autoinflammatory Diseases, Autoimmune Diseases and Primary Immunodeficiencies, Barcelona, Spain
- *Correspondence: José Hernández-Rodríguez,
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Magen E, Mukherjee S, Bhattacharya M, Detroja R, Merzon E, Blum I, Livoff A, Shlapobersky M, Baum G, Talisman R, Cherniavsky E, Dori A, Frenkel-Morgenstern M. Clinical and Molecular Characterization of a Rare Case of BNT162b2 mRNA COVID-19 Vaccine-Associated Myositis. Vaccines (Basel) 2022; 10:vaccines10071135. [PMID: 35891299 PMCID: PMC9324661 DOI: 10.3390/vaccines10071135] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 07/12/2022] [Accepted: 07/13/2022] [Indexed: 12/18/2022] Open
Abstract
Initial clinical trials and surveillance data have shown that the most commonly administered BNT162b2 COVID-19 mRNA vaccine is effective and safe. However, several cases of mRNA vaccine-induced mild to moderate adverse events were recently reported. Here, we report a rare case of myositis after injection of the first dose of BNT162b2 COVID-19 mRNA vaccine into the left deltoid muscle of a 34-year-old, previously healthy woman who presented progressive proximal muscle weakness, progressive dysphagia, and dyspnea with respiratory failure. One month after vaccination, BNT162b2 vaccine mRNA expression was detected in a tissue biopsy of the right deltoid and quadriceps muscles. We propose this case as a rare example of COVID-19 mRNA vaccine-induced myositis. This study comprehensively characterizes the clinical and molecular features of BNT162b2 mRNA vaccine-associated myositis in which the patient was severely affected.
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Affiliation(s)
- Eli Magen
- Medicine C Department, Clinical Immunology and Allergy Division, Barzilai University Medical Center, Ben-Gurion University of the Negev, Ashkelon 7830604, Israel;
- Leumit Health Services, Tel Aviv 6473817, Israel;
- Correspondence: (E.M.); (M.F.-M.)
| | - Sumit Mukherjee
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel; (S.M.); (M.B.); (R.D.); (G.B.)
- Department of Computer Science, Ben-Gurion University, Beer-Sheva 8410501, Israel
| | - Mahua Bhattacharya
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel; (S.M.); (M.B.); (R.D.); (G.B.)
| | - Rajesh Detroja
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel; (S.M.); (M.B.); (R.D.); (G.B.)
| | - Eugene Merzon
- Leumit Health Services, Tel Aviv 6473817, Israel;
- Department of Family Medicine, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Idan Blum
- Medicine C Department, Clinical Immunology and Allergy Division, Barzilai University Medical Center, Ben-Gurion University of the Negev, Ashkelon 7830604, Israel;
| | - Alejandro Livoff
- Pathology Department, Barzilai University Medical Center, Ashkelon 7830604, Israel; (A.L.); (M.S.)
| | - Mark Shlapobersky
- Pathology Department, Barzilai University Medical Center, Ashkelon 7830604, Israel; (A.L.); (M.S.)
| | - Gideon Baum
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel; (S.M.); (M.B.); (R.D.); (G.B.)
| | - Ran Talisman
- Plastic Surgery Department, Barzilai University Medical Center, Ashkelon 7830604, Israel;
| | - Evgenia Cherniavsky
- Imaging Department, Barzilai University Medical Center, Ashkelon 7830604, Israel;
| | - Amir Dori
- Department of Neurology, Sheba Medical Center, Ramat Gan 5262000, Israel;
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Milana Frenkel-Morgenstern
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel; (S.M.); (M.B.); (R.D.); (G.B.)
- Correspondence: (E.M.); (M.F.-M.)
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14
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SARS-CoV-2 Vaccination: What Can We Expect Now? Vaccines (Basel) 2022; 10:vaccines10071093. [PMID: 35891257 PMCID: PMC9319792 DOI: 10.3390/vaccines10071093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 06/21/2022] [Accepted: 06/27/2022] [Indexed: 11/17/2022] Open
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15
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Wee LE, Tan JY, Ko KKK, Wan WY, Lai DCM, Oon LLE, Tan-Garcia A, Yeong JPS, Pena AMT, Lim TKH, Conceicao EP, Venkatachalam I, Wijaya L, Tan TT. Detection of viable SARS-CoV-2 in deep respiratory specimens despite negative nasopharyngeal SARS-CoV-2 RT-PCR: Occult COVID-19 as an unsuspected cause of pulmonary infiltrates in immunocompromised patients. IDCases 2022; 30:e01611. [PMID: 36032521 PMCID: PMC9395297 DOI: 10.1016/j.idcr.2022.e01611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/19/2022] [Accepted: 08/20/2022] [Indexed: 11/08/2022] Open
Abstract
Background Prolonged shedding/relapse of COVID-19 infection has been reported, particularly in patients who received anti-CD20 agents (eg. rituximab). However, cases of occult COVID-19, in which SARS-CoV-2 persistence in lung parenchyma is diagnosed despite clearance from nasopharyngeal (NP) specimens, are uncommon. Case summary We describe two cases of occult COVID-19 in immunocompromised patients. Both patients had received rituximab previously. Both cases initially presented as ground-glass infiltrates on lung imaging; the diagnosis was originally not suspected due to repeated demonstration of negative SARS-CoV-2 from NP specimens, and alternative etiologies were originally considered. Persistence of SARS-CoV-2 in lung parenchyma, however, was demonstrated on bronchoalveolar lavage (BAL) specimens; additionally, isolation of viable SARS-CoV-2 virus and detection of SARS-CoV-2 nucleocapsid and spike-protein antigen in lung tissue on immunohistochemistry close to 3-months from primary infection strongly suggested ongoing viral persistence and replication as a driver of the lung parenchymal changes, which resolved after antiviral treatment. Discussion Occult COVID-19 can be a cause of unexplained ground-glass infiltrates on lung imaging; negative NP samples do not rule out SARS-CoV-2 persistence and invasive sampling must be considered. The unsuspected presence of viable virus on BAL, however, highlights that procedurists perfoming aerosol-generating-procedures during an ongoing pandemic wave must also practise appropriate infection-prevention precautions to limit potential exposure.
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