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Simon Frances B, Nair N, Gaur A, Plotz B, Majumdar A. Spectre of COVID-19 infection confounding myocarditis related to cytomegalovirus mononucleosis syndrome and hyperinflammatory syndrome. Heliyon 2023; 9:e21383. [PMID: 37942169 PMCID: PMC10628695 DOI: 10.1016/j.heliyon.2023.e21383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 10/13/2023] [Accepted: 10/20/2023] [Indexed: 11/10/2023] Open
Abstract
Viral infections have multiple mechanisms of affecting internal and external organs by direct invasion or by molecular mimicry. They have also been described as triggers for inflammatory processes like hyperinflammatory syndrome (HIS), Adult-onset Stills Disease (AOSD), and myocarditis [1]. Here we report an interesting case of a young adult with recent infection with SARS-CoV-2 (COVID-19) who presented with myocarditis requiring circulatory support in the cardiac care unit. During the admission, he was found to have concurrent cytomegalovirus (CMV) mononucleosis syndrome and presentation consistent with HIS resembling AOSD. This patient had multiple etiologies that could have caused myocarditis: CMV infection, COVID-19 infection, and HIS. As noted, viral infections have been proposed as potential triggers for the onset of HIS and AOSD with unknown mechanisms. We aim to add to the literature regarding CMV infection in an immunocompetent host causing myocarditis and HIS with features of AOSD with recent history of COVID-19 infection.
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Affiliation(s)
| | - Namitha Nair
- Department of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Aahana Gaur
- Department of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Benjamin Plotz
- Department of Rheumatology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Anjali Majumdar
- Division of Allergy, Immunology and Infectious Diseases, Department of Medicine, Rutgers University Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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Pinal-Fernandez I, Pak K, Gil-Vila A, Baucells A, Plotz B, Casal-Dominguez M, Derfoul A, Martinez MA, Selva-O’Callaghan A, Sabbagh S, Casciola-Rosen L, Albayda J, Paik J, Tiniakou E, Danoff SK, Lloyd TE, Miller FW, Rider LG, Christopher-Stine L, Mammen AL. Anti-Cortactin Autoantibodies Are Associated With Key Clinical Features in Adult Myositis But Are Rarely Present in Juvenile Myositis. Arthritis Rheumatol 2022; 74:358-364. [PMID: 34313394 PMCID: PMC8792092 DOI: 10.1002/art.41931] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 06/15/2021] [Accepted: 06/22/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To define the prevalence and clinical phenotype of anti-cortactin autoantibodies in adult and juvenile myositis. METHODS In this longitudinal cohort study, anti-cortactin autoantibody titers were assessed by enzyme-linked immunosorbent assay in 670 adult myositis patients and 343 juvenile myositis patients as well as in 202 adult healthy controls and 90 juvenile healthy controls. The prevalence of anti-cortactin autoantibodies was compared among groups. Clinical features of patients with and those without anti-cortactin autoantibodies were also compared. RESULTS Anti-cortactin autoantibodies were more common in adult dermatomyositis (DM) patients (15%; P = 0.005), particularly those with coexisting anti-Mi-2 autoantibodies (24%; P = 0.03) or anti-NXP-2 autoantibodies (23%; P = 0.04). In adult myositis, anti-cortactin was associated with DM skin involvement (62% of patients with anti-cortactin versus 38% of patients without anti-cortactin; P = 0.03), dysphagia (36% versus 17%; P = 0.02) and coexisting anti-Ro 52 autoantibodies (47% versus 26%; P = 0.001) or anti-NT5c1a autoantibodies (59% versus 33%; P = 0.001). Moreover, the titers of anti-cortactin antibodies were higher in patients with interstitial lung disease (0.15 versus 0.12 arbitrary units; P = 0.03). The prevalence of anti-cortactin autoantibodies was not different in juvenile myositis patients (2%) or in any juvenile myositis subgroup compared to juvenile healthy controls (4%). Nonetheless, juvenile myositis patients with these autoantibodies had a higher prevalence of "mechanic's hands" (25% versus 7%; P = 0.03), a higher number of hospitalizations (2.9 versus 1.3; P = 0.04), and lower peak creatine kinase values (368 versus 818 IU/liter; P = 0.02) than those without anti-cortactin. CONCLUSION The prevalence of anti-cortactin autoantibodies is increased in adult DM patients with coexisting anti-Mi-2 or anti-NXP-2 autoantibodies. In adults, anti-cortactin autoantibodies are associated with dysphagia and interstitial lung disease.
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Affiliation(s)
- Iago Pinal-Fernandez
- Muscle Disease Unit, Laboratory of Muscle Stem Cells and Gene Regulation, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland.,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Faculty of Health Sciences, and Faculty of Computer Science, Multimedia and Telecommunications, Universitat Oberta de Catalunya, Barcelona, Spain
| | - Katherine Pak
- Muscle Disease Unit, Laboratory of Muscle Stem Cells and Gene Regulation, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland
| | - Albert Gil-Vila
- Vall d’Hebron Hospital, Barcelona, Spain.,Autonomous University of Barcelona, Barcelona, Spain
| | | | - Benjamin Plotz
- Division of Rheumatology, New York University Langone Health, New York, NY
| | - Maria Casal-Dominguez
- Muscle Disease Unit, Laboratory of Muscle Stem Cells and Gene Regulation, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland.,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Assia Derfoul
- Muscle Disease Unit, Laboratory of Muscle Stem Cells and Gene Regulation, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland
| | | | | | - Sara Sabbagh
- Division of Rheumatology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Livia Casciola-Rosen
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jemima Albayda
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Julie Paik
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Eleni Tiniakou
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sonye K. Danoff
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Thomas E. Lloyd
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Frederick W. Miller
- Environmental Autoimmunity Group, Clinical Research Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Bethesda, MD
| | - Lisa G. Rider
- Environmental Autoimmunity Group, Clinical Research Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Bethesda, MD
| | - Lisa Christopher-Stine
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew L. Mammen
- Muscle Disease Unit, Laboratory of Muscle Stem Cells and Gene Regulation, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland.,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Izmirly PM, Kim MY, Samanovic M, Fernandez-Ruiz R, Ohana S, Deonaraine KK, Engel AJ, Masson M, Xie X, Cornelius AR, Herati RS, Haberman RH, Scher JU, Guttmann A, Blank RB, Plotz B, Haj-Ali M, Banbury B, Stream S, Hasan G, Ho G, Rackoff P, Blazer AD, Tseng CE, Belmont HM, Saxena A, Mulligan MJ, Clancy RM, Buyon JP. Evaluation of Immune Response and Disease Status in SLE Patients Following SARS-CoV-2 Vaccination. Arthritis Rheumatol 2021; 74:284-294. [PMID: 34347939 PMCID: PMC8426963 DOI: 10.1002/art.41937] [Citation(s) in RCA: 91] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/09/2021] [Accepted: 07/29/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate seroreactivity and disease flares after COVID-19 vaccination in a multi-ethnic/racial cohort of patients with systemic lupus erythematosus (SLE). METHODS 90 SLE patients and 20 healthy controls receiving a complete COVID-19 vaccine regimen were included. IgG seroreactivity to the SARS-CoV-2 spike receptor-binding domain (RBD) and SARS-CoV-2 microneutralization were used to evaluate B cell responses; IFN-γ production to assess T cell responses was measured by ELISpot. Disease activity was measured by the hybrid SLE disease activity index (SLEDAI) and flares were assigned by the SELENA/SLEDAI flare index. RESULTS Overall, fully vaccinated SLE patients produced significantly lower IgG antibodies against SARS-CoV-2 spike RBD than controls. Twenty-six SLE patients (28.8%) generated an IgG response below that of the lowest control (<100 units/ml). In logistic regression analyses, the use of any immunosuppressant or prednisone and a normal anti-dsDNA level prior to vaccination associated with decreased vaccine responses. IgG seroreactivity to the SARS-CoV-2 Spike RBD strongly correlated with the SARS-CoV-2 microneutralization titers and antigen-specific IFN-γ production determined by ELISpot. In a subset of patients with poor antibody responses, IFN-γ production was likewise diminished. Pre-/post-vaccination SLEDAI scores were similar. Only 11.4% of patients had a post-vaccination flare; 1.3% were severe. CONCLUSION In a multi-ethnic/racial study of SLE patients 29% had a low response to the COVID-19 vaccine which was associated with being on immunosuppression. Reassuringly, disease flares were rare. While minimal protective levels remain unknown, these data suggest protocol development is needed to assess efficacy of booster vaccination.
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Affiliation(s)
- Peter M Izmirly
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Mimi Y Kim
- Division of Biostatistics, Department of Epidemiology & Population Health, Albert Einstein College of Medicine, 1300 Morris Park Ave, The Bronx, New York, NY, 10461, USA
| | - Marie Samanovic
- Division of Infectious Diseases and Immunology, Department of Medicine, NYU Langone Vaccine Center, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Ruth Fernandez-Ruiz
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Sharon Ohana
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Kristina K Deonaraine
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Alexis J Engel
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Mala Masson
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Xianhong Xie
- Division of Biostatistics, Department of Epidemiology & Population Health, Albert Einstein College of Medicine, 1300 Morris Park Ave, The Bronx, New York, NY, 10461, USA
| | - Amber R Cornelius
- Division of Infectious Diseases and Immunology, Department of Medicine, NYU Langone Vaccine Center, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Ramin S Herati
- Division of Infectious Diseases and Immunology, Department of Medicine, NYU Langone Vaccine Center, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Rebecca H Haberman
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Jose U Scher
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Allison Guttmann
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Rebecca B Blank
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Benjamin Plotz
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Mayce Haj-Ali
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Brittany Banbury
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Sara Stream
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Ghadeer Hasan
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Gary Ho
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Paula Rackoff
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Ashira D Blazer
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Chung-E Tseng
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - H Michael Belmont
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Amit Saxena
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Mark J Mulligan
- Division of Infectious Diseases and Immunology, Department of Medicine, NYU Langone Vaccine Center, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Robert M Clancy
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Jill P Buyon
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
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