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Barreira-Díaz A, Riveiro-Barciela M, Fernández-Bonilla EM, Bernal V, Castiella A, Casado-Martín M, Delgado C, Londoño MC, Díaz-González Á, Pérez-Medrano I, Conthe A, Sala M, Mateos B, Gómez-Camarero J, Antón-Conejero D, Pozo-Calzada CD, Cuenca F, Villagrasa-Vilella A, Salcedo M. Outcomes and factors associated with relapse of vaccine-induced liver injury after SARS CoV-2 immunization: A nationwide study. Ann Hepatol 2024; 29:101489. [PMID: 38403068 DOI: 10.1016/j.aohep.2024.101489] [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: 08/30/2023] [Revised: 11/13/2023] [Accepted: 12/05/2023] [Indexed: 02/27/2024]
Abstract
INTRODUCTION AND OBJECTIVES Different patterns of liver injury have been reported in association with the SARS-CoV-2 vaccines. The aim of this study was to describe a nationwide cohort of patients with SARS CoV-2 vaccine-induced liver injury, focusing on treatment and the evolution after further booster administration. PATIENTS AND METHODS multicentre, retrospective-prospective study, including subjects who developed abnormal liver tests within 90 days after administration of SARS-CoV-2 vaccination. RESULTS 47 cases were collected: 17 after prime dose and 30 after booster. Age was 57 years, 30 (63.8 %) were female, and 7 (14.9 %) had a history of prior autoimmune hepatitis (AIH). Most cases were non-severe, though 9 (19.1 %) developed acute liver injury or failure (ALF). Liver injury tended to be more severe in those presenting after a booster (p=0.084). Pattern of liver injury was hepatocellular (80.9 %), mixed (12.8 %) and 3 (6.4 %) cholestatic. Liver biopsy was performed on 33 patients; 29 showed findings of AIH. Forty-one (87.2 %) patients received immunosuppressants, mostly corticosteroids (35/41). One required liver transplantation and another died due to ALF. Immunosuppression was discontinued in 6/41 patients without later rebound. Twenty-five subjects received at least one booster and 7 (28.0 %) relapsed from the liver injury, but all were non-severe. Recurrence was less frequent among patients on immunosuppressants at booster administration (28.6 % vs. 88.9 %, p=0.007). CONCLUSIONS SARS CoV-2 vaccine-induced liver injury is heterogeneous but mostly immune-mediated. Relapse of liver injury after re-exposure to vaccine is frequent (28.0 %) but mild. Immunosuppression at booster administration is associated with a lower risk of liver injury.
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Affiliation(s)
- Ana Barreira-Díaz
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain; Liver Unit, Hospital Universitario Vall de Hebrón, Barcelona, Spain
| | - Mar Riveiro-Barciela
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Liver Unit, Hospital Universitario Vall de Hebrón, Barcelona, Spain.
| | | | - Vanesa Bernal
- Gastroenterology and Hepatology Department, Miguel Servet University Hospital, Zaragoza, Spain
| | | | | | | | - María-Carlota Londoño
- Institut D'Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Liver Unit, Hospital Clínic Barcelona, University of Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Álvaro Díaz-González
- Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Valdecilla Biomedical Research Institute (IDIVAL), Santander, Spain
| | - Indhira Pérez-Medrano
- Gastroenterology and Hepatology Department, Complejo Hospitalario Universitario de Pontevedra, Spain
| | - Andrés Conthe
- Hepatology and Liver Transplantation Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Margarita Sala
- Gastroenterology Department, Hospital Universitari Josep Trueta, Girona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Beatriz Mateos
- Digestive Department, Hospital Ramón y Cajal, Madrid, Spain
| | | | - Dolores Antón-Conejero
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Digestive Department, Hospital Universitario Dr. Peset, Valencia, Spain
| | | | - Francisca Cuenca
- Gastroenterology Department, Hospital Clínico San Carlos, Madrid, Spain
| | - Ares Villagrasa-Vilella
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain; Liver Unit, Hospital Universitario Vall de Hebrón, Barcelona, Spain
| | - Magdalena Salcedo
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Hepatology and Liver Transplantation Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Kochhar S, Assis DN, Mack C, Izurieta HS, Muratori L, Munoz A, Nordenberg D, Gidudu JF, Blau EF, Vierling JM. Autoimmune hepatitis: Brighton Collaboration case definition and guidelines for data collection, analysis, and presentation of immunisation safety data. Vaccine 2024; 42:1812-1825. [PMID: 38368225 PMCID: PMC11648169 DOI: 10.1016/j.vaccine.2024.01.021] [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: 12/01/2023] [Accepted: 01/05/2024] [Indexed: 02/19/2024]
Abstract
This report introduces a Brighton Collaboration (BC) case definition for autoimmune hepatitis (AIH), which has been classified as a priority adverse event of special interest (AESI), as there were possible cases seen following COVID-19 vaccination. The case definition was developed by a group of subject matter and BC process experts to facilitate safety data comparability across pre- and post-licensure clinical trials, as well as pharmacovigilance activities in multiple settings with diverse resources and healthcare access. The usual BC case definition development process was followed in an expedited manner, and took two months to complete, including finalising the manuscript for publication, instead of the usual 1 year development time. It includes a systematic review of the literature and an expert consensus to define levels of diagnostic certainty for AIH, and provides specific guidelines for data collection and analysis. Histology, serological and biochemical tests and exclusion of alternate diagnosis were considered necessary to define the levels of certainty (definitive, probable and possible). AEFI reports of suspected AIH were independently classified by the WG members to test its useability and these classifications were used to finalise the case definition. The document underwent peer review by external AIH experts and a Reference Group of vaccine safety stakeholders in high-, low- and middle-income countries to ensure case definition useability, applicability, and scientific integrity. The expedited process can be replicated for development of other standardised case definitions for priority AESIs for endemics and epidemics. While applicable to cases reported following immunisation, the case definition is independent of lapsed time following vaccination and, as such, can also be used to determine background incidence for vaccinated and unvaccinated control groups in studies of causal association. While use of this case definition is also appropriate for the study of safety of other products including drugs, it is not meant to guide clinical case management.
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Affiliation(s)
- Sonali Kochhar
- Department of Global Health, University of Washington, Seattle, WA, USA; Global Healthcare Consulting, New Delhi, India.
| | - David N Assis
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA.
| | - Cara Mack
- Medical College of Wisconsin, Children's Wisconsin, Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Milwaukee, WI, USA.
| | | | - Luigi Muratori
- DIMEC Università di Bologna and IRCCS Policlinico di Sant'Orsola, Bologna, Italy.
| | - Alma Munoz
- Instituto de Salud Pública, Santiago, Chile.
| | - Dale Nordenberg
- Thriive, 250 - 25th Street, West Vancouver, BC V7V 4J1, USA.
| | - Jane F Gidudu
- Global Immunization Division, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Erin F Blau
- Global Immunization Division, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - John M Vierling
- Departments of Medicine and Surgery, Baylor College of Medicine, USA.
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Bernasconi E, Biagi M, Di Agostino S, Cursaro C, Felicani C, Ronconi E, Franchi E, Costanzo AC, Gabrielli F, Cavicchioli A, Ienopoli G, Marenghi P, Bartoli A, Serra B, Scalabrini D, Sighinolfi P, Andreone P. Investigating Acute Hepatitis after SARS-CoV-2 Vaccination or Infection: A Genetic Case Series. Biomedicines 2023; 11:2848. [PMID: 37893221 PMCID: PMC10604753 DOI: 10.3390/biomedicines11102848] [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: 09/10/2023] [Revised: 10/14/2023] [Accepted: 10/16/2023] [Indexed: 10/29/2023] Open
Abstract
(1) Background: Despite the advantages of COVID-19 vaccination, rare cases of acute hepatitis developing after the administration of the COVID-19 vaccine or the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have been reported. The aim of the study is to describe a case series of patients who experienced the onset of acute hepatitis, with or without autoimmune features, following SARS-CoV-2 vaccination or infection and to hypothesize a genetic susceptibility in the pathogenesis. (2) Methods: A group of patients with acute onset hepatitis following SARS-CoV-2 vaccination or infection were evaluated in our hepatology outpatient clinic, where they underwent biochemical and autoimmune tests. Hepatitis A (HAV), B (HBV), and C virus (HCV), cytomegalovirus (CMV), Epstein-Barr virus (EBV), and human immunodeficiency virus (HIV) infections were excluded. Patients with a diagnosis of autoimmune hepatitis (AIH) or drug-induced liver injury (DILI) underwent HLA typing and histological testing. (3) Results: Five patients experienced new-onset AIH after COVID-19 vaccination, one of which developed mild symptoms after vaccination that strongly worsened during subsequent SARS-CoV-2 infection. One patient had AIH relapse after COVID-19 vaccination while on maintenance immunosuppressive treatment. All of them had HLA DRB1 alleles known to confer susceptibility to AIH (HLA DRB1*03,*07,*13,*14), and in three of them, HLA DRB1*11 was also detected. Two patients developed acute hepatitis without autoimmune hallmarks which resolved spontaneously, both positive for HLA DRB1*11. (4) Conclusions: An association between AIH and COVID-19 vaccine or infection can be hypothesized in individuals with a genetic predisposition. In patients without autoimmune features and spontaneous improvement of hypertransaminasemia, the diagnosis of drug-induced liver injury (DILI) is probable. Further studies are needed to determine the presence of an actual association and identify a possible role of HLA DRB1*11 in the pathogenesis of acute liver injury after SARS-CoV2 vaccination or infection.
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Affiliation(s)
- Elisa Bernasconi
- Department of Internal Medicine, Civil Hospital of Baggiovara, University of Modena and Reggio Emilia, Baggiovara, 41126 Modena, Italy; (E.B.); (M.B.); (S.D.A.); (C.C.); (C.F.); (E.R.); (E.F.); (A.C.C.); (F.G.); (A.C.); (G.I.); (P.M.); (A.B.); (B.S.); (D.S.); (P.S.)
| | - Matteo Biagi
- Department of Internal Medicine, Civil Hospital of Baggiovara, University of Modena and Reggio Emilia, Baggiovara, 41126 Modena, Italy; (E.B.); (M.B.); (S.D.A.); (C.C.); (C.F.); (E.R.); (E.F.); (A.C.C.); (F.G.); (A.C.); (G.I.); (P.M.); (A.B.); (B.S.); (D.S.); (P.S.)
| | - Stefania Di Agostino
- Department of Internal Medicine, Civil Hospital of Baggiovara, University of Modena and Reggio Emilia, Baggiovara, 41126 Modena, Italy; (E.B.); (M.B.); (S.D.A.); (C.C.); (C.F.); (E.R.); (E.F.); (A.C.C.); (F.G.); (A.C.); (G.I.); (P.M.); (A.B.); (B.S.); (D.S.); (P.S.)
| | - Carmela Cursaro
- Department of Internal Medicine, Civil Hospital of Baggiovara, University of Modena and Reggio Emilia, Baggiovara, 41126 Modena, Italy; (E.B.); (M.B.); (S.D.A.); (C.C.); (C.F.); (E.R.); (E.F.); (A.C.C.); (F.G.); (A.C.); (G.I.); (P.M.); (A.B.); (B.S.); (D.S.); (P.S.)
| | - Cristina Felicani
- Department of Internal Medicine, Civil Hospital of Baggiovara, University of Modena and Reggio Emilia, Baggiovara, 41126 Modena, Italy; (E.B.); (M.B.); (S.D.A.); (C.C.); (C.F.); (E.R.); (E.F.); (A.C.C.); (F.G.); (A.C.); (G.I.); (P.M.); (A.B.); (B.S.); (D.S.); (P.S.)
| | - Enrico Ronconi
- Department of Internal Medicine, Civil Hospital of Baggiovara, University of Modena and Reggio Emilia, Baggiovara, 41126 Modena, Italy; (E.B.); (M.B.); (S.D.A.); (C.C.); (C.F.); (E.R.); (E.F.); (A.C.C.); (F.G.); (A.C.); (G.I.); (P.M.); (A.B.); (B.S.); (D.S.); (P.S.)
| | - Elena Franchi
- Department of Internal Medicine, Civil Hospital of Baggiovara, University of Modena and Reggio Emilia, Baggiovara, 41126 Modena, Italy; (E.B.); (M.B.); (S.D.A.); (C.C.); (C.F.); (E.R.); (E.F.); (A.C.C.); (F.G.); (A.C.); (G.I.); (P.M.); (A.B.); (B.S.); (D.S.); (P.S.)
| | - Arianna Carmen Costanzo
- Department of Internal Medicine, Civil Hospital of Baggiovara, University of Modena and Reggio Emilia, Baggiovara, 41126 Modena, Italy; (E.B.); (M.B.); (S.D.A.); (C.C.); (C.F.); (E.R.); (E.F.); (A.C.C.); (F.G.); (A.C.); (G.I.); (P.M.); (A.B.); (B.S.); (D.S.); (P.S.)
| | - Filippo Gabrielli
- Department of Internal Medicine, Civil Hospital of Baggiovara, University of Modena and Reggio Emilia, Baggiovara, 41126 Modena, Italy; (E.B.); (M.B.); (S.D.A.); (C.C.); (C.F.); (E.R.); (E.F.); (A.C.C.); (F.G.); (A.C.); (G.I.); (P.M.); (A.B.); (B.S.); (D.S.); (P.S.)
| | - Alessia Cavicchioli
- Department of Internal Medicine, Civil Hospital of Baggiovara, University of Modena and Reggio Emilia, Baggiovara, 41126 Modena, Italy; (E.B.); (M.B.); (S.D.A.); (C.C.); (C.F.); (E.R.); (E.F.); (A.C.C.); (F.G.); (A.C.); (G.I.); (P.M.); (A.B.); (B.S.); (D.S.); (P.S.)
| | - Giuseppe Ienopoli
- Department of Internal Medicine, Civil Hospital of Baggiovara, University of Modena and Reggio Emilia, Baggiovara, 41126 Modena, Italy; (E.B.); (M.B.); (S.D.A.); (C.C.); (C.F.); (E.R.); (E.F.); (A.C.C.); (F.G.); (A.C.); (G.I.); (P.M.); (A.B.); (B.S.); (D.S.); (P.S.)
| | - Paolo Marenghi
- Department of Internal Medicine, Civil Hospital of Baggiovara, University of Modena and Reggio Emilia, Baggiovara, 41126 Modena, Italy; (E.B.); (M.B.); (S.D.A.); (C.C.); (C.F.); (E.R.); (E.F.); (A.C.C.); (F.G.); (A.C.); (G.I.); (P.M.); (A.B.); (B.S.); (D.S.); (P.S.)
| | - Alessandra Bartoli
- Department of Internal Medicine, Civil Hospital of Baggiovara, University of Modena and Reggio Emilia, Baggiovara, 41126 Modena, Italy; (E.B.); (M.B.); (S.D.A.); (C.C.); (C.F.); (E.R.); (E.F.); (A.C.C.); (F.G.); (A.C.); (G.I.); (P.M.); (A.B.); (B.S.); (D.S.); (P.S.)
| | - Beatrice Serra
- Department of Internal Medicine, Civil Hospital of Baggiovara, University of Modena and Reggio Emilia, Baggiovara, 41126 Modena, Italy; (E.B.); (M.B.); (S.D.A.); (C.C.); (C.F.); (E.R.); (E.F.); (A.C.C.); (F.G.); (A.C.); (G.I.); (P.M.); (A.B.); (B.S.); (D.S.); (P.S.)
| | - Davide Scalabrini
- Department of Internal Medicine, Civil Hospital of Baggiovara, University of Modena and Reggio Emilia, Baggiovara, 41126 Modena, Italy; (E.B.); (M.B.); (S.D.A.); (C.C.); (C.F.); (E.R.); (E.F.); (A.C.C.); (F.G.); (A.C.); (G.I.); (P.M.); (A.B.); (B.S.); (D.S.); (P.S.)
| | - Pamela Sighinolfi
- Department of Internal Medicine, Civil Hospital of Baggiovara, University of Modena and Reggio Emilia, Baggiovara, 41126 Modena, Italy; (E.B.); (M.B.); (S.D.A.); (C.C.); (C.F.); (E.R.); (E.F.); (A.C.C.); (F.G.); (A.C.); (G.I.); (P.M.); (A.B.); (B.S.); (D.S.); (P.S.)
| | - Pietro Andreone
- Department of Internal Medicine, Civil Hospital of Baggiovara, University of Modena and Reggio Emilia, Baggiovara, 41126 Modena, Italy; (E.B.); (M.B.); (S.D.A.); (C.C.); (C.F.); (E.R.); (E.F.); (A.C.C.); (F.G.); (A.C.); (G.I.); (P.M.); (A.B.); (B.S.); (D.S.); (P.S.)
- Department of Internal Medicine, General, Emergency and Post-Acute, Division of Metabolic Internal Medicine, Civil Hospital of Baggiovara, Azienda Ospedaliero-Universitaria di Modena, Baggiovara, 41126 Modena, Italy
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Aghamohamadi N, Shahba F, Zarezadeh Mehrabadi A, Khorramdelazad H, Karimi M, Falak R, Emameh RZ. Age-dependent immune responses in COVID-19-mediated liver injury: focus on cytokines. Front Endocrinol (Lausanne) 2023; 14:1139692. [PMID: 37654571 PMCID: PMC10465349 DOI: 10.3389/fendo.2023.1139692] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 07/21/2023] [Indexed: 09/02/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is potentially pathogenic and causes severe symptoms; in addition to respiratory syndromes, patients might experience other severe conditions such as digestive complications and liver complications injury. The abnormality in the liver is manifested by hepatobiliary dysfunction and enzymatic elevation, which is associated with morbidity and mortality. The direct cytopathic effect, immune dysfunction, cytokine storm, and adverse effects of therapeutic regimens have a crucial role in the severity of liver injury. According to aging and immune system alterations, cytokine patterns may also change in the elderly. Moreover, hyperproduction of cytokines in the inflammatory response to SARS-CoV-2 can lead to multi-organ dysfunction. The mortality rate in elderly patients, particularly those with other comorbidities, is also higher than in adults. Although the pathogenic effect of SARS-CoV-2 on the liver has been widely studied, the impact of age and immune-mediated responses at different ages remain unclear. This review discusses the association between immune system responses in coronavirus disease 2019 (COVID-19) patients of different ages and liver injury, focusing on cytokine alterations.
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Affiliation(s)
- Nazanin Aghamohamadi
- Department of Immunology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Faezeh Shahba
- Department of Immunology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Zarezadeh Mehrabadi
- Department of Immunology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Hossein Khorramdelazad
- Department of Immunology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
- Department of Immunology, School of Medicine, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Milad Karimi
- Department of Immunology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Reza Falak
- Department of Immunology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Reza Zolfaghari Emameh
- Department of Energy and Environmental Biotechnology, National Institute of Genetic Engineering and Biotechnology (NIGEB), Tehran, Iran
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Sergi CM. COVID-19 vaccination-related autoimmune hepatitis-a perspective. Front Pharmacol 2023; 14:1190367. [PMID: 37601060 PMCID: PMC10435075 DOI: 10.3389/fphar.2023.1190367] [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] [Received: 03/20/2023] [Accepted: 07/17/2023] [Indexed: 08/22/2023] Open
Abstract
Autoimmune hepatitis (AIH) is the inflammation of the liver with clear-cut interface hepatitis and piecemeal necrosis located at the boundary between portal areas and periportal hepatocytes, and characterized by autoimmunity to hepatocytes with an increase in the antinuclear antibody. After the disastrous SARS-CoV-2 pandemic flagellated several countries, several vaccines have been commercialized and have become a ground for social responsibility. The mRNA vaccines, issued by Pfizer-BioNTech (BNT162b2) and Moderna (mRNA-1273), do not use prebuilt viruses to supply the antigen in the subject's body and are not perfect but have been useful in tackling the pandemic. Nevertheless, both myocarditis and AIH have been reported as side effects of the vaccination programs in addition to thromboembolic events. Here, we explore this topic and give a data-based perspective, gathering a comparison between the titin protein of the sarcomere and myocarditis. The isolation of a Drosophila gene using the serum from a patient with autoimmune scleroderma recognized an epitope on chromosomes (condensed mitotic form) in both human cultured cells and early Drosophila embryos. It revealed that this gene encodes a Drosophila homolog of the vertebrate titin (D-Titin). Moreover, anti-titin antibodies have been found in a subset of patients with myasthenia gravis, a neuromuscular junction disease that is mostly associated with autoimmune antibodies, such as the anti-acetylcholine receptor antibody. The co-existence of myasthenia gravis and autoimmune hepatitis is rare, and a cohort of patients with myasthenia gravis anti-titin antibodies seems to be highly relevant. In consideration of these data and the number of patients who may not be symptomatic, we postulated that autoimmune phenomena may not be exceedingly rare, following the administration of mRNA technology-based vaccines, and a balance between pros and cons in administrating boosters is critical.
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Affiliation(s)
- Consolato M. Sergi
- AP Division, Pathology Laboratories, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
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Wang M, Qi J, Liu Y. Autoimmune hepatitis following COVID-19 vaccination: Clinical characteristics of 35 reported cases. Drug Discov Ther 2023:2023.01022. [PMID: 37331808 DOI: 10.5582/ddt.2023.01022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
The coronavirus disease 2019 (COVID-19) vaccines have been shown to be effective in protecting people from severe disease progression, hospitalisation and death. However, a wide range of side effects have been reported worldwide. New onset or flare-up of autoimmune hepatitis (AIH) is an extremely rare adverse event following COVID-19 vaccination, with the majority of cases presenting with mild symptoms. Unfortunately, there have been cases of fatal complications. In this mini-review, we have summarised the clinical characteristics of a total of 35 currently reported cases of AIH after COVID-19 vaccination and suggest that patients with autoimmune diseases may be at higher risk of developing AIH after vaccination.
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Affiliation(s)
| | - Juan Qi
- Qingdao Municipal Hospital, Qingdao, China
| | - Yujuan Liu
- Qingdao Women and Children's Hospital, Qingdao, China
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Czaja AJ. Incorporating the Molecular Mimicry of Environmental Antigens into the Causality of Autoimmune Hepatitis. Dig Dis Sci 2023:10.1007/s10620-023-07967-5. [PMID: 37160542 PMCID: PMC10169207 DOI: 10.1007/s10620-023-07967-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 05/01/2023] [Indexed: 05/11/2023]
Abstract
Molecular mimicry between foreign and self-antigens has been implicated as a cause of autoimmune hepatitis in experimental models and cross-reacting antibodies in patients. This review describes the experimental and clinical evidence for molecular mimicry as a cause of autoimmune hepatitis, indicates the limitations and uncertainties of this premise, and encourages investigations that assess diverse environmental antigens as sources of disease-relevant molecular mimics. Pertinent articles were identified in PubMed using multiple search phrases. Several pathogens have linear or conformational epitopes that mimic the self-antigens of autoimmune hepatitis. The occurrence of an acute immune-mediated hepatitis after vaccination for severe acute respiratory syndrome (SARS)-associated coronavirus 2 (SARS-CoV-2) has suggested that vaccine-induced peptides may mimic disease-relevant tissue antigens. The intestinal microbiome is an under-evaluated source of gut-derived antigens that could also engage in molecular mimicry. Chaperone molecules may enhance the pathogenicity of molecular mimics, and they warrant investigation. Molecular mimics of immune dominant epitopes within cytochrome P450 IID6, the autoantigen most closely associated with autoimmune hepatitis, should be sought in diverse environmental antigens and assessed for pathogenicity. Avoidance strategies, dietary adjustments, vaccine improvement, and targeted manipulation of the intestinal microbiota may emerge as therapeutic possibilities. In conclusion, molecular mimicry may be a missing causality of autoimmune hepatitis. Molecular mimics of key immune dominant epitopes of disease-specific antigens must be sought in diverse environmental antigens. The ubiquity of molecular mimicry compels rigorous assessments of peptide mimics for immunogenicity and pathogenicity in experimental models. Molecular mimicry may complement epigenetic modifications as causative mechanisms of autoimmune hepatitis.
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Affiliation(s)
- Albert J Czaja
- Professor Emeritus of Medicine, Mayo Clinic College of Medicine and Science, 200 First Street SW, Rochester, MN, 55905, USA.
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Scholkmann F, May CA. COVID-19, post-acute COVID-19 syndrome (PACS, "long COVID") and post-COVID-19 vaccination syndrome (PCVS, "post-COVIDvac-syndrome"): Similarities and differences. Pathol Res Pract 2023; 246:154497. [PMID: 37192595 DOI: 10.1016/j.prp.2023.154497] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/25/2023] [Accepted: 05/01/2023] [Indexed: 05/18/2023]
Abstract
Worldwide there have been over 760 million confirmed coronavirus disease 2019 (COVID-19) cases, and over 13 billion COVID-19 vaccine doses have been administered as of April 2023, according to the World Health Organization. An infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can lead to an acute disease, i.e. COVID-19, but also to a post-acute COVID-19 syndrome (PACS, "long COVID"). Currently, the side effects of COVID-19 vaccines are increasingly being noted and studied. Here, we summarise the currently available indications and discuss our conclusions that (i) these side effects have specific similarities and differences to acute COVID-19 and PACS, that (ii) a new term should be used to refer to these side effects (post-COVID-19 vaccination syndrome, PCVS, colloquially "post-COVIDvac-syndrome"), and that (iii) there is a need to distinguish between acute COVID-19 vaccination syndrome (ACVS) and post-acute COVID-19 vaccination syndrome (PACVS) - in analogy to acute COVID-19 and PACS ("long COVID"). Moreover, we address mixed forms of disease caused by natural SARS-CoV-2 infection and COVID-19 vaccination. We explain why it is important for medical diagnosis, care and research to use the new terms (PCVS, ACVS and PACVS) in order to avoid confusion and misinterpretation of the underlying causes of disease and to enable optimal medical therapy. We do not recommend to use the term "Post-Vac-Syndrome" as it is imprecise. The article also serves to address the current problem of "medical gaslighting" in relation to PACS and PCVS by raising awareness among the medical professionals and supplying appropriate terminology for disease.
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Affiliation(s)
- Felix Scholkmann
- University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland.
| | - Christian-Albrecht May
- Department of Anatomy, Faculty of Medicine Carl Gustav Carus, TU Dresden, 01307 Dresden, Germany
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Guo M, Liu X, Chen X, Li Q. Insights into new-onset autoimmune diseases after COVID-19 vaccination. Autoimmun Rev 2023; 22:103340. [PMID: 37075917 PMCID: PMC10108562 DOI: 10.1016/j.autrev.2023.103340] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 04/13/2023] [Indexed: 04/21/2023]
Abstract
Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has resulted in more than 670 million infections and almost 7 million deaths globally. The emergence of numerous SARS-CoV-2 has heightened public concern regarding the future course of the epidemic. Currently, the SARS-CoV-2 Omicron variant has rapidly become globally dominant in the COVID-19 pandemic due to its high infectivity and immune evasion. Consequently, vaccination implementation is critically significant. However, growing evidence suggests that COVID-19 vaccination may cause new-onset autoimmune diseases, including autoimmune glomerulonephritis, autoimmune rheumatic diseases, and autoimmune hepatitis. Nevertheless, the causal relationship between COVID-19 vaccines and these autoimmune diseases remains to be demonstrated. In this review, we provide evidence that vaccination induces autoimmunity and summarize possible mechanisms of action, such as molecular mimicry, activation by bystanders, and adjuvants. Our objective is not to refute the importance of vaccines, but to raise awareness about the potential risks of COVID-19 vaccination. In fact, we believe that the benefits of vaccination far outweigh the possible risks and encourage people to get vaccinated.
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Affiliation(s)
- Ming Guo
- Hebei General Hosptial, Shijiazhuang, China; Hebei Medical University, Shijiazhuang, China
| | - Xiaoxiao Liu
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Nephrology Institute of the Chinese People's Liberation Army, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research, Beijing 100853, China
| | - Xiangmei Chen
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Nephrology Institute of the Chinese People's Liberation Army, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research, Beijing 100853, China
| | - Qinggang Li
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Nephrology Institute of the Chinese People's Liberation Army, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research, Beijing 100853, China.
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Sgamato C, Rocco A, Compare D, Minieri S, Marchitto SA, Maurea S, Nardone G. Autoimmune liver diseases and SARS-CoV-2. World J Gastroenterol 2023; 29:1838-1851. [PMID: 37032727 PMCID: PMC10080695 DOI: 10.3748/wjg.v29.i12.1838] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 01/12/2023] [Accepted: 03/14/2023] [Indexed: 03/28/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causing coronavirus disease 2019 (COVID-19), can trigger autoimmunity in genetically predisposed individuals through hyperstimulation of immune response and molecular mimicry. Here we summarise the current knowledge about auto-immune liver diseases (AILDs) and SARS-CoV-2, focusing on: (1) The risk of SARS-CoV-2 infection and the course of COVID-19 in patients affected by AILDs; (2) the role of SARS-CoV-2 in inducing liver damage and triggering AILDs; and (3) the ability of vaccines against SARS-CoV-2 to induce autoimmune responses in the liver. Data derived from the literature suggest that patients with AILDs do not carry an increased risk of SARS-Cov-2 infection but may develop a more severe course of COVID-19 if on treatment with steroids or thiopurine. Although SARS-CoV-2 infection can lead to the development of several autoimmune diseases, few reports correlate it to the appearance of de novo manifestation of immune-mediated liver diseases such as autoimmune hepatitis (AIH), primary biliary cholangitis (PBC) or AIH/PBC overlap syndrome. Different case series of an AIH-like syndrome with a good prognosis after SARS-CoV-2 vaccination have been described. Although the causal link between SARS-CoV-2 vaccines and AIH cannot be definitively established, these reports suggest that this association could be more than coincidental.
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Affiliation(s)
- Costantino Sgamato
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples 80131, Italy
| | - Alba Rocco
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples 80131, Italy
| | - Debora Compare
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples 80131, Italy
| | - Stefano Minieri
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples 80131, Italy
| | - Stefano Andrea Marchitto
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples 80131, Italy
| | - Simone Maurea
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples 80131, Italy
| | - Gerardo Nardone
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples 80131, Italy
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Cunha-Silva M, de França EVC, Greca RD, Mazo DFDC, da Costa LBE, de Moraes PBS, Veiga CT, Assis-Mendonça GR, Boin IDFSF, Stucchi RSB, Sevá-Pereira T. Autoimmune hepatitis and primary biliary cholangitis overlap syndrome after COVID-19. Autops Case Rep 2023; 13:e2023422. [PMID: 37034275 PMCID: PMC10075219 DOI: 10.4322/acr.2023.422] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 02/10/2023] [Indexed: 04/07/2023]
Abstract
COVID-19 is commonly associated with high serum levels of pro-inflammatory cytokines, and the post-infection status can disturb self-tolerance and trigger autoimmune responses. We are reporting a 45-year-old male who was admitted with fatigue, jaundice, elevated liver enzymes (with cholestatic pattern), and acute kidney injury two weeks after recovering from a mild SARS-CoV-2 infection. Serologies for viral hepatitis and anti-mitochondrial antibody were negative, while anti-nuclear and anti-smooth muscle antibodies were positive. There were no signs of chronic liver disease, and a magnetic resonance cholangiography showed no dilatation of biliary ducts. Histologic evaluation of the liver evidenced numerous foci of lobular necrosis without ductopenia or portal biliary reaction. Considering the autoantibody profile and histologic changes, the medical team started oral prednisone, but there was a suboptimal biochemical response in the outpatient follow-up. Two months later, a second liver biopsy was performed and revealed non-suppurative destructive chronic cholangitis, extensive areas of confluent necrosis with hepatocytes regenerating into pseudorosettes, and numerous plasma cells. According to the Paris Criteria, the patient was then diagnosed with an autoimmune hepatitis-primary biliary cholangitis overlap syndrome (AIH-PBC-OS). After adding azathioprine and ursodeoxycholic acid to the treatment, there was a satisfactory response. This is the second worldwide report of an AIH-PBC-OS triggered by COVID-19, but the first case with a negative anti-mitochondrial antibody. In this setting, histologic evaluation of the liver by an experienced pathologist is a hallmark of achieving the diagnosis and correctly treat the patient.
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Affiliation(s)
- Marlone Cunha-Silva
- Universidade Estadual de Campinas (UNICAMP), School of Medical Sciences, Centro de Diagnóstico de Doenças do Aparelho Digestivo (GASTROCENTRO), Department of Internal Medicine, Division of Gastroenterology, Campinas, SP, Brasil
| | - Eloy Vianey Carvalho de França
- Universidade Estadual de Campinas (UNICAMP), School of Medical Sciences, Centro de Diagnóstico de Doenças do Aparelho Digestivo (GASTROCENTRO), Department of Internal Medicine, Division of Gastroenterology, Campinas, SP, Brasil
| | - Raquel Dias Greca
- Universidade Estadual de Campinas (UNICAMP), School of Medical Sciences, Centro de Diagnóstico de Doenças do Aparelho Digestivo (GASTROCENTRO), Department of Internal Medicine, Division of Gastroenterology, Campinas, SP, Brasil
| | - Daniel Ferraz de Campos Mazo
- Universidade Estadual de Campinas (UNICAMP), School of Medical Sciences, Centro de Diagnóstico de Doenças do Aparelho Digestivo (GASTROCENTRO), Department of Internal Medicine, Division of Gastroenterology, Campinas, SP, Brasil
| | - Larissa Bastos Eloy da Costa
- Universidade Estadual de Campinas (UNICAMP), School of Medical Sciences, Department of Pathology, Campinas, SP, Brasil
| | - Priscilla Brito Sena de Moraes
- Universidade Estadual de Campinas (UNICAMP), School of Medical Sciences, Centro de Diagnóstico de Doenças do Aparelho Digestivo (GASTROCENTRO), Department of Internal Medicine, Division of Gastroenterology, Campinas, SP, Brasil
| | - Clauber Teles Veiga
- Universidade Estadual de Campinas (UNICAMP), School of Medical Sciences, Centro de Diagnóstico de Doenças do Aparelho Digestivo (GASTROCENTRO), Department of Internal Medicine, Division of Gastroenterology, Campinas, SP, Brasil
| | | | | | - Raquel Silveira Bello Stucchi
- Universidade Estadual de Campinas (UNICAMP), School of Medical Sciences, Department of Internal Medicine, Division of Infectious Diseases, Campinas, SP, Brasil
| | - Tiago Sevá-Pereira
- Universidade Estadual de Campinas (UNICAMP), School of Medical Sciences, Centro de Diagnóstico de Doenças do Aparelho Digestivo (GASTROCENTRO), Department of Internal Medicine, Division of Gastroenterology, Campinas, SP, Brasil
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Vaccine-Related Autoimmune Hepatitis: Emerging Association with SARS-CoV-2 Vaccination or Coincidence? Vaccines (Basel) 2022; 10:vaccines10122073. [PMID: 36560483 PMCID: PMC9783100 DOI: 10.3390/vaccines10122073] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 11/30/2022] [Accepted: 12/01/2022] [Indexed: 12/09/2022] Open
Abstract
BACKGROUND There is an increasing number of liver injury cases resembling autoimmune hepatitis (AIH) following SARS-CoV-2 vaccination; however, an association has not yet been established. METHODS/MATERIALS A literature review was performed to identify articles regarding the association of AIH with vaccination, emphasizing on SARS-CoV-2 vaccines, and the proposed mechanisms. We then performed a literature search for AIH-like cases following SARS-CoV-2 vaccination, and we evaluated the included cases for AIH diagnosis using simplified diagnostic criteria (SDC), and for vaccination causality using the Naranjo score for adverse drug reactions. RESULTS We identified 51 AIH-like cases following SARS-CoV-2 vaccination. Forty cases (80%) were characterized as "probable", "at least probable", or "definite" for AIH diagnosis according to SDC. Forty cases (78.4%) were characterized as "probable", four (7.8%) as "possible", and three (5.8%) as "definite" for vaccine-related AIH according to the Naranjo score. CONCLUSION SARS-CoV-2 vaccine-related AIH carries several phenotypes and, although most cases resolve, immunosuppressive therapy seems to be necessary. Early diagnosis is mandatory and should be considered in any patient with acute or chronic hepatitis after SARS-CoV-2 vaccination, especially in those with pre-existing liver disease.
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