New-onset autoimmune phenomena post COVID-19 vaccination

Neutralizing antibodies against SARS-CoV-2 of vaccinated healthcare workers in Taiwan

BACKGROUND

Vaccination is one of the best ways to control the SARS-CoV-2 outbreak. In Taiwan, healthcare workers were prioritized for vaccination, but the effectiveness of these vaccines for them remains unclear. Thus, it's essential to examine their neutralizing antibodies after prime-boost vaccinations.

METHODS

In this prospective observational study, 514 healthcare workers from Chang Gung Memorial hospitals in Taiwan were included between 19 March 2021 and 21 August 2021. The two doses of COVID-19 vaccines were either a match or a mixing of AZD1222 and mRNA-1273, e.g. AZD1222 + AZD1222 (n = 406), mRNA-1273 + mRNA-1273 (n = 62), and AZD1222 + mRNA-1273 (n = 46). Blood specimens were drawn after two doses of vaccines, defined as post-vaccine days [median 34.00 days and interquartile range (IQR) 29.00-42.00 days], and examined for the neutralizing antibodies via SARS-CoV-2 neutralization kits. The results were analyzed as a percentage of inhibition based on the negative control.

RESULTS

After 2 vaccination doses, subjects with AZD1222 + mRNA-1273 (median 97.15%, IQR 96.06-98.06%) and mRNA-1273 + mRNA-1273 (median 97.47%, IQR 96.75-97.89%) exhibited higher neutralizing antibodies than those receiving AZD1222 + AZD1222 vaccines (median 71.28%, IQR 49.39-89.70%) (the percentage was referred to inhibition of surrogate virus). The post-vaccination days negatively impacted the neutralizing antibodies, except for the mRNA-1273 + mRNA-1273 group. The presence of fever, headache, and myalgia after the second dosage was reflected in the higher neutralizing antibodies (median of no fever 76.00% vs. fever 97.00%, p < 0.0001; median of no headache 76.00% vs. headache 95.00%, p < 0.0001; median of no myalgia 75.50% vs. myalgia 96.00%, p < 0.0001). The subjects with underlying diseases, including hypertension and cancer showed lower neutralizing antibodies (median of no hypertension 81.00% vs. hypertension 56.00%, p = 0.0029; median of no cancer 81.00% vs. cancer 56.00%, p = 0.0143).

CONCLUSION

Heterologous prime-boost vaccines (AZD1222 + mRNA-1273) and two doses of mRNA vaccines are recommended. For future directions, we need to investigate the effectiveness of the vaccination against new SARS-CoV-2 variants.

Detection of S1 spike protein in CD16+ monocytes up to 245 days in SARS-CoV-2-negative post-COVID-19 vaccine syndrome (PCVS) individuals

Despite over 13 billion SARS-CoV-2 vaccine doses administered globally, persistent post-vaccination symptoms, termed post-COVID-19 vaccine syndrome (PCVS), resemble post-acute sequelae of COVID-19 (PASC). Symptoms like cardiac, vascular, and neurological issues often emerge shortly after vaccination and persist for months to years, mirroring PASC. We previously showed the S1 subunit of the SARS-CoV-2 spike protein persists in CD16+ monocytes after infection, potentially driving PASC. Approved vaccines (Pfizer, Moderna, Janssen, AstraZeneca) deliver synthetic S1 to elicit immunity, suggesting a shared mechanism. We hypothesized that vaccine-derived S1 persistence in CD16+ monocytes sustains inflammation akin to PASC, contributing to PCVS. We studied 50 individuals with PCVS symptoms lasting over 30 days post-vaccination and 26 asymptomatic controls, using (1) machine learning-based immune profiling to compare cytokine signatures with PASC, (2) flow cytometry to detect S1 in CD16+ monocytes, and (3) LC-MS to confirm S1 across vaccine types. We correlated S1 persistence with symptom duration and inflammation. Prior infection was excluded via clinical history, anti-nucleocapsid antibody tests, and T-detect assays, though definitive tests are lacking. Preliminary findings suggest S1 persistence in CD16+ monocytes and an associated inflammatory profile may contribute to PCVS. Further studies are needed to confirm causality and prevalence.

New-onset drug-resistant epilepsy in type 1 diabetes mellitus patient following COVID-19 vaccination: suspicious for autoimmune pathogenesis

INTRODUCTION

Within the spectrum of epilepsies, autoimmune-associated epilepsy (AAE) reflects the complexity of its presentations including refractory seizures along with cognitive decline and behavioral or psychiatric dysfunction. The suspicion of autoimmune epilepsy is heightened in individuals who have a pre-existing autoimmune condition, such as type 1 diabetes mellitus (T1DM). This report details a case of autoimmune epilepsy associated with Glutamic acid decarboxylase (GAD65) antibodies coexisting with T1DM.

CASE DESCRIPTION

The subject of this clinical case is a 48-year-old male with a history of T1DM and hypothyroidism, who exhibited new behavioral alterations and refractory focal seizures two weeks post- COVID-19 vaccination. Initially, his symptoms were misinterpreted as panic attacks. Months later, these attacks were diagnosed as focal epilepsy after multiple evaluations including, interictal and ictal electroencephalograms, brain Magnetic Resonance Imaging (MRI), and Positron Emission Tomography (PET). The patient underwent several trials of antiseizure medications and their combinations, yet no significant effects were observed. The Antibody Prevalence in Epilepsy and Encephalopathy (APE2) score was determined, yielding a result of 4, and the presence of elevated Glutamic acid decarboxylase (GAD65) antibodies in the serum led to a confirmed diagnosis of autoimmune encephalitis (AAE). Following a course of intravenous immunoglobulin, no notable improvement was recorded; however, subsequent corticosteroid therapy, accompanied by rigorous blood glucose monitoring, resulted in a positive but partial reduction in seizure frequency. The patient was planned to start on long-term use of azathioprine.

CONCLUSION

This case exemplifies the diagnostic challenges inherent in autoimmune-associated epilepsy and underscores the necessity for prompt intervention. Glutamic acid decarboxylase (GAD65) antibody-associated autoimmune epilepsy should be suspected in adult-onset temporal lobe epilepsy with co-morbid type 1 DM with early initiation of immune therapy for better clinical outcomes.

Unprecedented case of rapid-onset autoimmune hepatitis triggered by COVID-19 mRNA vaccination, complicated by concurrent severe hemophagocytic lymphohistiocytosis and acute liver failure in a previously healthy adult: a multidisciplinary approach and review of therapeutic interventions

A previously healthy 35-year-old male developed acute autoimmune hepatitis 5 weeks after receiving his second dose of an mRNA vaccine, presenting with jaundice, elevated liver enzymes, and abdominal pain. The condition rapidly progressed to severe hemophagocytic lymphohistiocytosis (HLH) and acute liver failure, confirmed by liver biopsy and bone marrow aspirate. Despite aggressive multidisciplinary treatment, including corticosteroids, immunoglobulin, and IL-1 antagonists, the patient deteriorated, developing multi-organ failure. Emergency liver transplantation was considered but was not viable due to his unstable condition. The case highlights a potential rare vaccine-associated immune response which we believe has not been reported in the literature, requiring prompt recognition and multidisciplinary management. Further research is needed to understand the underlying immunogenic triggers and optimize treatment.

Two adolescents with frequently relapsing nephrotic syndrome newly diagnosed after SARS-CoV-2 vaccination: case report and literature review

Even though several cases of new-onset nephrotic syndrome following vaccination against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been reported, none have included the medium- to long-term prognosis of the patients. Here, we report the prognoses of two adolescents, aged 14 and 15 years, who developed nephrotic syndrome soon after receiving the Pfizer-BioNTech SARS-CoV-2 vaccine. Both patients were diagnosed with nephrotic syndrome after developing edema within a few days post-SARS-CoV-2 vaccination. Although they achieved rapid and complete remission with prednisolone therapy, they developed frequently relapsing nephrotic syndrome and were initiated on cyclosporine. In one patient, frequent relapses occurred while taking cyclosporine, requiring rituximab to maintain remission. Measurements of antibody titers against the spike protein of the SARS-CoV-2 vaccine taken over time revealed significantly lower titers in both patients compared with those in healthy individuals. Furthermore, each patient was infected with SARS-CoV-2 about 12 months post vaccination, with mild symptoms. Nephrotic syndrome did not recur in either patient. We also reviewed 49 published cases of patients who developed nephrotic syndrome after SARS-CoV-2 vaccination, compared to our pediatric cases, there are no cases of recurrence with the same frequency in adult cases, and it is desirable to accumulate and compare more pediatric cases in the future.

Mechanistic considerations linking SARS-CoV-2 infection, inflammation, and the loss of immune tolerance

The immune response to SARS-CoV-2 has been implicated in the onset of multiple, seemingly unrelated, autoimmune diseases. The immune response to SARS-CoV-2 has also been implicated in the unmasking and/or production of multiple autoantibodies, even in the absence of clinical disease. Despite such data, it remains unclear whether antibodies targeting antiviral signaling proteins and mitochondrial antigens reflect bystander activation or alternatively contribute to de novo viral immune escape mechanisms. With these comments in mind, a variety of professional antibody presenting cells and including lung resident macrophages of COVID-19 infected patients are impacted and dependent on the uptake of antibody-opsonized virus by Fcγ receptors; yet infection is aborted via antibody-dependent effector mechanisms or pyroptosis, possibly leading to autoantibody production, and autoinflammatory manifestations, respectively. TRIM21/Ro52, a cytosolic E3-ubiquitin ligase with an Fc-gamma receptor domain, functions as an intracytoplasmic antibody receptor, directs immune complexes binding virions but also autoantigens to autophagy. During autophagy, Ig-virions-TRIM21/Ro52-autoantigens complexes bind directly to class II human leukocyte antigen in lysosomal compartment, leading to subsequent presentation on the cell surface. This process favors the development of a specific humoral immune response but has the potential to lead to loss of tolerance. Interestingly, TRIM21/Ro52 can also contribute to pyroptosis. We propose that TRIM21/Ro52 is well-placed at the crossroad between the inflammatory response and clinical autoimmunity.

Investigating the association between SARS-CoV-2 infection, COVID-19 vaccination, and autoimmune diseases in a pediatric population: a comprehensive analysis

BACKGROUND

During the COVID-19 pandemic there were reports of an increased association between COVID 19 and various autoimmune diseases (AID) in adults. This study aims to investigate the incidence of AIDs in children before and during the pandemic and explores potential links to SARS-CoV-2 vaccination.

METHODS

We analyzed 493,705 anonymized medical records from Maccabi Healthcare Services, Israel's second-largest healthcare provider, to study AID incidence during 2014-2022. The study period was divided into three phases: two pre-pandemic phases of equal duration (A and B) and a pandemic phase (C).

RESULTS

Of 4,596 (0.9%) patients diagnosed with an AID in the cohort, incidence rates were 0.9% for Group A (2014-2016), 1.0% for Group B (2017-2019), and 0.9% for Group C (2020-2022) (p = 0.13). Logistic regression showed no significant differences in overall autoimmune disease incidence between the pre-COVID and COVID periods. Notably, specific conditions like celiac disease showed reduced incidence in Group A (OR 0.8309, p = 0.0071) while arthritis was significantly more common in Groups A and B. Additionally, COVID-19 diagnosis was not significantly associated with increased autoimmune disease risk (HR 1.092, p = 0.491); however, receiving at least one COVID vaccine was linked to higher risk (HR 1.2323, p = 0.0033).

CONCLUSION

Our findings suggest that the overall incidence of new-onset autoimmune diseases in children remained relatively stable during the COVID-19 pandemic. The study indicates a potential association between COVID-19 vaccination and an increased risk of developing autoimmune diseases, necessitating further research to elucidate long-term effects in the pediatric population.

A pilot study on the effect of SARS-CoV-2 spike protein on IL-1β-mediated inflammation in peripheral blood immune cells from AIED patients

BACKGROUND

Immune-mediated hearing loss (IMHL) patients (comprised of autoimmune inner ear disease (AIED) and sudden sensorineural hearing loss (SSNHL)) may be at higher risk for hearing loss following Coronavirus disease (COVID-19) infection and/or vaccination.

METHODS

We compared inflammatory cytokine expression in response to SARS-CoV2 spike protein between two groups of patients with IMHL: IMHL patients that temporally demonstrated worsening SNHL following COVID vaccination or infection as compared to IMHL patients with worsening SNHL unrelated to COVID exposure: (IMHL-COVID ( +)) (n = 11) (IMHL-COVID (-)) (n = 10). In these two groups, we treated isolated PBMCs with increasing amounts of SARS-CoV-2 spike protein and compared responses to stimulation with positive and negative controls.

RESULTS

Peripheral Blood Mononuclear Cells (PBMC) from IMHL-COVID ( +) patients had increased expression and release of both IL-1β and IL-6 in response to spike protein as compared to IMHL-COVID (-) patients. However, when the IMHL-COVID ( +) group was broken down into AIED patients compared to SSNHL, it became apparent that the greatest responses were from the AIED patients (p < 0.005 for IL-6 mRNA expression and p < 0.003 for IL-6 release when compared between any two similar groups using Wilcoxon Rank-Sum Test). When we broke down the COVID ( +) group to infection versus vaccination, the immune responses in the infection group (N = 3 AIED, 1 SSNHL) were stronger.

CONCLUSIONS

COVID-19 exposure with reported changes in hearing sensitivity in IMHL patients resulted in pro-inflammatory responses in response to spike protein. The inflammatory responses were greatest in AIED patients, and greater following infection rather than vaccination. Therefore, based on these studies, we would recommend AIED patients take additional precautions to avoid COVID exposure. Furthermore, we do recommend COVID vaccination during periods of hearing stability, as the immune responses are even more robust in response to infection in this vulnerable group.

Can Labs Help With Vaccination? In Vitro Tests in Diagnosis of Allergy to COVID-19 Vaccines-A Systematic Review

INTRODUCTION

Since the outbreak of the coronavirus pandemic in 2019, vaccinations have proven to be a key strategy in disease prophylaxis. Although vaccines are safe from the perspective of the general population, hypersensitivity reactions have still been described, causing individuals to be reluctant in their vaccination decision. Since the description of first reports of COVID-19 vaccine allergy, many protocols of allergy work-up have been developed, including In Vitro and In Vivo tests. Although In Vivo tests were more accessible, many patients preferred In Vitro tests that would not involve contact with the allergen and be safe. This applied in particular to patients that had experienced a severe delayed hypersensitivity reaction in which In Vivo tests were highly limited and provocations were deemed high risk. Taking into account these circumstances, In Vitro tests might significantly enhance allergy work-up.

METHODS

National Center for Biotechnology Information (Pubmed) database was searched in May 2024 for articles on In Vitro diagnostic methods for COVID-19 vaccine allergy and hypersensitivity.

RESULTS

This article describes the In Vitro tests developed to date in the diagnosis of COVID-19 vaccine hypersensitivity: (1) analysis of specific IgE and IgG, (2) Basophil Activation Test, (3) Histamine Release Test, (4) IgM-dependent complement activation, (5) Lymphocyte Transformation Test, (6) Flow cytometry T-Cell markers, (7) Th1/Th2 cytokines concentration in cell culture.

CONCLUSIONS

The article highlights the tests' advantages, flaws and possible clinical applications.

Artificial intelligence challenge of discriminating cutaneous arteritis and polyarteritis nodosa based on hematoxylin-and-eosin images of skin biopsy specimens

Diseases that develop necrotizing vasculitis of cutaneous muscular arteries include cutaneous arteritis (CA) and polyarteritis nodosa (PAN). It is difficult to distinguish them based on skin biopsy findings alone. This study demonstrated that artificial intelligence (AI) can discriminate them based on skin biopsy findings and revealed where AI focuses on the image. Ninety-three hematoxylin-and-eosin images of CA and 19 PAN images were used. Among them, 85 CA and 17 PAN images were used to train AI; thereafter, AI was challenged to classify the remaining images. The same test images were evaluated by 26 pathologists with different years of experience. AI accuracy was 75.2 %, whereas that of pathologists was 42.8 %. Gradient-weighted class activation mapping (Grad-CAM) indicated that AI focused on connective tissues around the affected vessels rather than the affected vessels. Twenty-two of the 26 pathologists were randomly divided into two groups of 11 each, one of which referred to Grad-CAM images and was challenged in the second-round test of images different from the first round. The accuracy significantly improved after referring to Grad-CAM images, whereas it was equivalent to the first round without referring to Grad-CAM images. In the survey after the second-round test, pathologists who referred to Grad-CAM images suggested that inflammation and fibrosis in the surrounding connective tissues in PAN might be abundant compared to CA. AI may be useful for histological differentiation between CA and PAN and can help pathologists improve the ability of discriminating CA and PAN based on histological findings of skin biopsy specimens.

Disproportionality analysis of European safety reports on autoimmune and rheumatic diseases following COVID-19 vaccination

The safety profile of COVID-19 vaccines is well-established, yet the widespread immunization campaign has led to an increase in reported cases of Immune-Mediated and Rheumatic Diseases (IMDRs). This study aimed to assess the reporting of Adverse Events Following Immunization (AEFIs) related to IMDRs after COVID-19 vaccination. We analyzed all individual case safety reports (ICSRs) related to COVID-19 vaccines authorized in the European Union (i.e., tozinameran, elasomeran, ChAdOx1-S NCoV-19, and Ad26.Cov2.S) registered in the EudraVigilance (EV) database from January 1, 2021, to October 23, 2023. Our analysis identified ICSRs with events indicative of IMDRs and conducted disproportionality analysis (i.e., Reporting Odds Ratio (ROR) with 95% CI) to examine the frequency of different IMDR types linked to each vaccine. In total, 45,352 ICSRs reported at least one AEFI associated with rheumatic or autoimmune conditions, with 54% of them implicating tozinameran as the suspected vaccine. More than half of the reported AEFIs were classified as serious, with approximately 45% remaining unresolved. The most frequently reported conditions were other immune-mediated diseases, followed by arthritis, vasculitis, systemic lupus erythematosus, and tendinopathies. Our disproportionality analysis suggested that mRNA vaccines may be more frequently associated with new autoimmune rheumatic diseases. Stratified analysis revealed significant associations for ChAd, particularly in vasculitis and tendinopathies, only when compared to Ad26.Cov2.S. Real-world pharmacovigilance data suggest that autoimmune and rheumatic diseases may be under-reported following COVID-19 vaccination, highlighting the need for further research to better understand the underlying mechanisms. The findings from this disproportionality analysis suggest the need for further studies to investigate these results in greater depth.

From infection to autoimmunity: can COVID-19 spark new auto-immune conditions?

Background

Some studies have described a probable relationship between SARS-CoV-2 infection and autoimmunity.

Aim

to present a case series of autoimmune manifestations (AIM) following COVID-19 infection.

Methods

A consecutive series of patients from January 2020 to December 2023 was collected from the various departments of Fattouma Bourguiba University Hospital, Monastir, where all clinical assessments were performed. Anti-nuclear antibody (ANA) screening was performed using indirect immunofluorescence on HEp-2 cells (Euroimmun, Germany) with a positivity titer of ≥1/180. Typing was performed using ELISA (Biosystems, Spain) or line blot (Euroimmun, Germany). The assessment of other autoantibodies was performed using various techniques (indirect immunofluorescence, ELISA, and line blot).

Results

Sixteen patients presented with AIM after the COVID-19 infection. Their ages ranged from 12 to 67 years (44.6 ± 15.5 years). The sex ratio was 1 (eight men to eight women). Clinical manifestations began between one week and three months after infection. The clinical presentation was polymorphic (general, cutaneous, neurological, ophthalmic, muscular, articular, and abdominal features). Biological, radiological, and histopathological investigations revealed principal abnormalities in endocrine, articular, muscular, or neurological functions in the presence of ANA and/or specific autoantibodies. Fiveteen patients were diagnosed with autoimmune diseases (AID) and treated with specific treatments. The diagnosis retained for the other case was non-specific autoimmune stimulation with spontaneous recovery.

Conclusion

These cases suggest that AID or AIM can be triggered or unmasked by SARS-CoV-2 infection.

Outcomes and risk factors of COVID-19 in patients with bullous pemphigoid: a cross-sectional study

Background

The outcomes of coronavirus disease 2019 (COVID-19) in patients with bullous pemphigoid (BP) remain insufficiently understood. This study aimed to evaluate the impact of COVID-19 on BP patients and identify factors influencing the risk and severity of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in BP patients.

Methods

A cross-sectional survey was conducted among BP patients in the Department of Dermatology at Shanghai Skin Disease Hospital from December 1, 2022, to March 1, 2023. Participants completed a comprehensive questionnaire addressing demographics, medical conditions, clinical symptoms, and behaviors during the COVID-19 pandemic. Factors influencing the risk of SARS-CoV-2 infection and its severity were evaluated by logistic regression.

Results

A total of 96 BP patients were analyzed. Demographic and clinical profiles, COVID-19-related characteristics, and the pandemic's impact on healthcare-seeking behaviors were described. Our findings showed that vaccination was associated with a reduced risk of SARS-CoV-2 infection (odds ratio [OR]: 0.157, 95% confidence interval [CI]: 0.045-0.552, p=0.002) and infection severity (OR: 0.044, 95% CI: 0.004-0.544, p=0.015). Furthermore, the use of prednisone at a dose >10 mg/day in the last 3 months was associated with an increased risk of SARS-CoV-2 infection (OR: 7.911, 95% CI: 1.379-45.393, p=0.012) but did not appear to influence infection severity.

Conclusions

The COVID-19 pandemic posed significant challenges for BP patients. Our study found that the use of prednisone at a dose >10 mg/day in the last three months was associated with an increased risk of SARS-CoV-2 infection. Vaccination provided protection against SARS-CoV-2 infection and severe COVID-19 in BP patients.

An adolescent presenting with IgA nephropathy and persistent decreased kidney function after COVID-19 vaccination during follow-up for asymptomatic hematuria: a clinicopathological study

Although the coronavirus disease 2019 (COVID-19) vaccine has been proven to be effective and safe in most adults and children, various diseases, including IgA nephropathy, sometimes occur as an adverse effect. We herein describe a case of IgA nephropathy in a 16-year-old, male patient with persistent kidney dysfunction following COVID-19 vaccination and present the clinicopathological course of the disease. The patient presented to the outpatient clinic with a history of gross hematuria 6 days after receiving the COVID-19 vaccine. Prior to the current presentation, he was being examined regularly at an outpatient clinic for asymptomatic hematuria. His mother had received a diagnosis of IgA nephropathy, and his younger brother had received a diagnosis of asymptomatic hematuria. A blood test of this patient demonstrated elevated serum creatinine, and IgA nephropathy was pathologically diagnosed (Oxford classification M0E1S1T0C1). Prednisolone and immunosuppressants were administered promptly to treat the decreased kidney function and the pathology. Nevertheless, the failure of his kidney function to recover to the state it was in prior to this episode may have led to the formation of chronic lesions, causing irreversible kidney tissue damage. Some patients with IgA nephropathy, asymptomatic hematuria or a family history of kidney-related symptoms may experience kidney dysfunction after COVID-19 vaccination and require prednisolone or immunosuppressive therapy to stem the progressive deterioration of their kidney function. Prior to receiving the COVID-19 vaccine, patients with any of these conditions should be provided with an appropriate explanation of the risks and be asked for their consent to be vaccinated.

Medium-vessel vasculitis following COVID-19 moderna (mRNA-1273) vaccination and the utility of PET-CT as a diagnostic tool: a case report

There have been several case reports of COVID-19 "BNT162b2" (Pfizer-BioNTech) and "mRNA-1273" (Moderna) vaccination associated small and medium vessel vasculitis described in the literature however none have had 18F-FDG Positron Emission Tomography scans (PET/CT) performed for diagnosis. We report the case of a 57-year-old Caucasian male patient from Australia where 18F-FDG PET/CT scanning facilitated early detection of a medium-vessel vasculitis following Moderna (mRNA-1273) COVID-19 vaccination. The diagnosis would otherwise have been difficult and allowed exclusion of alternative diagnoses and sparing of more invasive investigations such as muscle biopsy. Our case highlights the development of a medium vessel vasculitis following mRNA based COVID-19 vaccination and demonstrates the utility of 18F-FDG PET/CT as an excellent non-invasive test for the detection of this serious rare and often difficult to diagnose condition.

Relapse Risk in Patients with Membranous Nephropathy after Inactivated COVID-19 Vaccination

BACKGROUND

Although there have been reports of relapse or worsening of membranous nephropathy after receiving vaccines against coronavirus disease 2019 (COVID-19), the causal relationship or association between them has not been established. This study aimed to investigate the occurrence of relapse or worsening of membranous nephropathy following inactivated COVID-19 vaccination.

METHODS

Patients who had been diagnosed with membranous nephropathy before receiving their first dose of vaccination, or before March 1, 2021, for unvaccinated patients, were included in the study. All patients were monitored at the Membranous Nephropathy Clinic of Huashan Hospital, Fudan University. The reasons for not receiving vaccines were investigated. The impact of COVID-19 vaccination on membranous nephropathy was assessed by comparing the relapse or worsening of membranous nephropathy within 12 months in vaccinated and unvaccinated patients with proteinuria <3.5 g/d. The baseline variables were balanced using cardinality matching.

RESULTS

A total of 353 patients with membranous nephropathy were included in the study, with 186 (53%) having received inactivated COVID-19 vaccines. Among the 167 unvaccinated participants, 114 (68%) expressed concerns about the possibility of disease relapse, and 47 (28%) were worried about the vaccine's efficacy due to their immunosuppressive therapy. Of the 239 participants with proteinuria <3.5 g/d, 152 were vaccinated, and 16 (11%) experienced a relapse or worsening of the disease during the follow-up period, which was similar to the 14 (16%) observed in the unvaccinated group. Following cardinality matching, there was no difference in the rate of relapse or worsening between the two groups, with 10 (13%) in the vaccinated group and 11 (15%) in the unvaccinated group (hazard ratio 0.98, 95% confidence interval 0.42-2.33).

CONCLUSION

Getting the inactivated COVID-19 vaccine may not increase risk of relapse or worsening in patients with membranous nephropathy.

Systemic lupus erythematosus: updated insights on the pathogenesis, diagnosis, prevention and therapeutics

Systemic lupus erythematosus (SLE) is a chronic inflammatory illness with heterogeneous clinical manifestations covering multiple organs. Diversified types of medications have been shown effective for alleviating SLE syndromes, ranging from cytokines, antibodies, hormones, molecular inhibitors or antagonists, to cell transfusion. Drugs developed for treating other diseases may benefit SLE patients, and agents established as SLE therapeutics may be SLE-inductive. Complexities regarding SLE therapeutics render it essential and urgent to identify the mechanisms-of-action and pivotal signaling axis driving SLE pathogenesis, and to establish innovative SLE-targeting approaches with desirable therapeutic outcome and safety. After introducing the research history of SLE and its epidemiology, we categorized primary determinants driving SLE pathogenesis by their mechanisms; combed through current knowledge on SLE diagnosis and grouped them by disease onset, activity and comorbidity; introduced the genetic, epigenetic, hormonal and environmental factors predisposing SLE; and comprehensively categorized preventive strategies and available SLE therapeutics according to their functioning mechanisms. In summary, we proposed three mechanisms with determinant roles on SLE initiation and progression, i.e., attenuating the immune system, restoring the cytokine microenvironment homeostasis, and rescuing the impaired debris clearance machinery; and provided updated insights on current understandings of SLE regarding its pathogenesis, diagnosis, prevention and therapeutics, which may open an innovative avenue in the fields of SLE management.

Revolutionizing immunization: a comprehensive review of mRNA vaccine technology and applications

Messenger RNA (mRNA) vaccines have emerged as a transformative platform in modern vaccinology. mRNA vaccine is a powerful alternative to traditional vaccines due to their high potency, safety, and efficacy, coupled with the ability for rapid clinical development, scalability and cost-effectiveness in manufacturing. Initially conceptualized in the 1970s, the first study about the effectiveness of a mRNA vaccine against influenza was conducted in 1993. Since then, the development of mRNA vaccines has rapidly gained significance, especially in combating the COVID-19 pandemic. Their unprecedented success during the COVID-19 pandemic, as demonstrated by the Pfizer-BioNTech and Moderna vaccines, highlighted their transformative potential. This review provides a comprehensive analysis of the mRNA vaccine technology, detailing the structure of the mRNA vaccine and its mechanism of action in inducing immunity. Advancements in nanotechnology, particularly lipid nanoparticles (LNPs) as delivery vehicles, have revolutionized the field. The manufacturing processes, including upstream production, downstream purification, and formulation are also reviewed. The clinical progress of mRNA vaccines targeting viruses causing infectious diseases is discussed, emphasizing their versatility and therapeutic potential. Despite their success, the mRNA vaccine platform faces several challenges, including improved stability to reduce dependence on cold chain logistics in transport, enhanced delivery mechanisms to target specific tissues or cells, and addressing the risk of rare adverse events. High costs associated with encapsulation in LNPs and the potential for unequal global access further complicate their widespread adoption. As the world continues to confront emerging viral threats, overcoming these challenges will be essential to fully harness the potential of mRNA vaccines. It is anticipated that mRNA vaccines will play a major role in defining and shaping the future of global health.

Post coronavirus-disease-vaccination immune reconstitution inflammatory syndrome in tuberculosis treatment: a case report

BACKGROUND

Tuberculosis immune reconstitution inflammatory syndrome is an uncommon condition caused by excessive immune response against Mycobacterium tuberculosis. We report on a case which may have been precipitated by coronavirus disease messenger ribonucleic acid vaccine booster.

CASE PRESENTATION

A 47-year old Indian man developed reactivation tuberculosis in the cervical lymph nodes in the setting of immune suppression caused by tumor necrosis factor inhibitor adalimumab. The symptoms improved with starting antituberculous therapy, but 5 days after receiving a coronavirus disease booster messenger ribonucleic acid vaccine, he had recurrence of severe constitutional symptoms. After a detailed evaluation, he was diagnosed with immune reconstitution inflammatory syndrome and was successfully treated with high-dose steroid therapy, which was weaned off over several weeks.

CONCLUSION

Immune reconstitution inflammatory syndrome should be considered as a differential in patients who develop paradoxical worsening of symptoms with antitubercular therapy in the setting of immune reconstitution. Hyperactive immune response after infection or messenger ribonucleic acid vaccine booster may have contributed to the development of immune reconstitution inflammatory syndrome syndrome in this patient.

A Series of Glomerular Diseases That Developed After COVID-19 Vaccination

Background Although the coronavirus disease 2019 (COVID-19) vaccine has been shown to be effective in preventing severe COVID-19 infection, many vaccine-related adverse events have been reported with the increasing use of COVID-19 vaccines based on messenger RNA (mRNA). Cases of new-onset and relapsing vaccine-related glomerular diseases, including minimal change disease (MCD), antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis, immunoglobulin (Ig)G4-related disease, and IgA nephropathy (IgAN), have been reported. Methods We present 30 patients who developed glomerular diseases after COVID-19 mRNA vaccination. We evaluated the clinical characteristics, vaccine types, and outcomes of 30 patients whose urinalysis results indicated proteinuria and/or occult blood after COVID-19 mRNA vaccination. For a definitive diagnosis, we performed a renal biopsy and evaluated their histological findings. Results Out of 30 patients, 19 (63.3%) were female, and 11 (36.7%) were male. The median age of the patient was 42.5 years (range, 24-66 years). Seventy-three percent of the patients received BioNTech Pfizer vaccines, and 26.7% received Moderna vaccines (mRNA-1273). Gross hematuria was observed in 83.3% of the patients, and 13.3% had nephrotic syndrome. Twenty patients with IgAN were diagnosed by renal biopsy, while the remaining were diagnosed with MCD (n=3), proliferative glomerulonephritis with monoclonal Ig deposits (PGNMID) (n=1), TAFRO syndrome (characterized by thrombocytopenia, anasarca (edema, pleural effusion, and ascites), fever, reticulin fibrosis/renal dysfunction, and organomegaly; n=1), and anti-glomerular basement membrane (GBM) disease (n=1). Four patients who previously underwent treatment for IgAN experienced exacerbation of urinary abnormalities and disease relapse. Conclusion In conclusion, various glomerular diseases were newly diagnosed after COVID-19 mRNA vaccination. Although their short-term outcomes seem favorable, some patients developed serious worsening renal function and nephrotic range proteinuria. Patients with vaccine-related glomerular disease should be monitored long-term to predict prognosis in the future.

Changes in the Incidence of Optic Neuritis before and after the Coronavirus Disease 2019 Outbreak: A Nationwide Study 2017-2022

PURPOSE

To determine the risk of optic neuritis (ON) during nonpharmaceutical interventions (NPI), vaccination, and infection phases of the coronavirus disease 2019 (COVID-19) pandemic in comparison with levels before the outbreak in pediatric and adult populations in South Korea.

DESIGN

A nationwide, population-based retrospective study.

PARTICIPANTS

South Korean individuals with a primary diagnosis of ON received between January 2017 and December 2022.

METHODS

The Korean Health Insurance Review and Assessment database was queried for new diagnoses of ON between January 2017 and December 2022. Data were divided into 4 periods: before COVID-19 (2017-2019), NPI (2020), nationwide vaccination (2021), and nationwide infection (2022). The risk of ON development for each period was calculated and compared with levels before COVID-19, with 95% confidence intervals (CIs) reported.

MAIN OUTCOME MEASURES

Incidence rate ratio (IRR) of ON for each period.

RESULTS

A total of 7216 patients (52.7% female patients) were included in the study, with patients receiving a diagnosis of ON as follows: 3770 patients before COVID-19 (2017-2019), 1193 patients during NPI, 1135 patients during vaccination, and 1118 patients during the infection phases. The annual incidence of ON during NPI (IRR, 0.92; 95% CI, 0.85-1.00; P = 0.043), vaccination (IRR, 0.88; 95% CI, 0.81-0.95; P = 0.001), and infection (IRR, 0.86; 95% CI, 0.80-0.93; P < 0.001) phases significantly decreased compared with levels before COVID-19 when adjusted for age and sex. The proportions of diagnosis with multiple sclerosis (MS), neuromyelitis optica (NMO), and acute disseminated encephalomyelitis (ADEM) among patients in whom ON developed increased significantly in 2021 in comparison with levels before COVID-19 (10.93% vs. 6.43%; P = 0.0002).

CONCLUSIONS

The risks of ON development during the NPI, vaccination, and infection phases of COVID-19 did not increase in comparison with levels before the outbreak in the general population. However, COVID-19 vaccination may be associated with increased risks of ON associated with diseases such as ADEM, MS, and NMO.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

More antibodies are not always better: Fc effector functions play a critical role in SARS-CoV-2 infection and protection

Traditional vaccinology has primarily focused on neutralizing antibody titers as the main correlate of vaccine efficacy, often overlooking the multifaceted roles of antibody Fc effector functions in orchestrating protective immune responses. Fc-mediated immune responses play a pivotal role in immune modulation and pathogen clearance. Emerging evidence from natural infections and vaccine studies highlights the critical contribution of Fc effector functions in determining the quality and durability of immunity. This work explores the limitations of current vaccine evaluation paradigms that prioritize neutralization over Fc effector mechanisms. It also describes findings from a study showing an unexpected role for SARS-CoV-2 anti-spike antibodies: both convalescent plasma and patient-derived monoclonal antibodies (mAbs) lead to maximum phagocytic capacity by monocytes at low concentrations, whereas at higher concentrations the phagocytic capacity was reduced. Given that the severity of COVID-19 disease and antibody titers are strongly positively correlated, this work challenges the paradigm that high antibodies offer better protection against severe disease. It is proposed that humoral and cellular responses elicited by vaccination should never be higher than those produced by natural infection. By integrating antibody Fc effector functions into vaccine development, a paradigm shift is proposed that emphasizes synergic antibody responses. Such an approach could transform vaccine efficacy assessment, enhance protection against dangerous pathogens, and drive innovation in vaccine design.

Post-COVID-19 Inflammatory Arthritis Treated With Upadacitinib: A Case Report

Two patients who developed inflammatory arthritis following COVID-19 infection are presented, characterized by arthralgias, arthritis, and elevated markers of inflammation (C-reactive protein). Both patients had clinically meaningful responses to treatment with upadacitinib, a Janus Kinase inhibitor (JAKi). This case report highlights the efficacy and safety of upadacitinib in the treatment of post-COVID-19 inflammatory arthritis.

Incidence and Association of Uveitis with COVID-19 Vaccination: A Systematic Review and Meta-Analysis

PURPOSE

In the wake of the COVID-19 pandemic, vaccines have been pivotal in curbing disease spread and severity. However, concerns over post-vaccination adverse events, including uveitis, an inflammatory ocular condition, have been noted. This systematic review and meta-analysis aimed to evaluate the incidence and association of uveitis following COVID-19 vaccination.

METHODS

A literature search was performed across several databases on October 21, 2023. Human studies examining the incidence of uveitis post-COVID-19 vaccination were included. The Newcastle-Ottawa Scale was used for quality appraisal of the included studies. Meta-analysis was performed to assess the overall incidence of uveitis and the relative risk of developing the condition post-vaccination. All statistical analyses were performed using R software version 4.3.

RESULTS

Six studies involving over 2 billion vaccine doses were included. The overall incidence of uveitis was 0.016% (95% CI: 0.010 to 0.026). No significant association was found between vaccination and the onset of uveitis (Relative Risk: 1.45 (95% CI: 0.82 to 2.57, p = 0.12) from four studies. The evidence quality was rated very low due to the limited number of studies and imprecision.

CONCLUSION

This analysis indicates a low incidence of uveitis following COVID-19 vaccination and no significant association with the vaccine. The findings are constrained by the small number of studies and low certainty of evidence, underscoring the need for further research. Comprehensive and longitudinal studies are necessary to confirm these findings and reinforce public confidence in COVID-19 vaccination programs.

Autoantibodies as potential prognostic factors for clinical outcomes related to COVID-19: a systematic review of inception prospective cohort studies with GRADE recommendations

This systematic review of inception prospective cohort studies aimed to investigate whether autoantibodies are potential prognostic factors for short- and long-term clinical outcomes of COVID-19. Searches were conducted in MEDLINE, EMBASE, AMED, GLOBAL HEALTH, and COCHRANE databases from 2019 to 2022. When possible, meta-analysis was conducted, otherwise findings from individual studies were reported using odds ratios (OR) with 95% confidence intervals (CI). Quality of evidence was summarized using the GRADE criteria. We identified 2292 references, 18 inception prospective cohort studies (3178 patients) were included in the systematic review, and 12 studies reached criteria for meta-analysis. Studies achieved, in general, low to moderate risk of bias. Moderate quality of evidence showed that anti-interferon (IFN) was associated with increased risk of severity (OR=7.75; CI=1.79-33.61) and mechanical ventilation (OR=4.19; CI=2.06-8.53), but not with COVID-19 mortality (OR=1.68; CI=0.63-4.44). Antiphospholipids were not associated with COVID-19 mortality (OR=1.42; CI=0.85-2.37; P=0.18; I2=3.21) nor with thrombosis risk (OR=1.41; CI: 0.71-2.8; P=0.33). Antinuclear antibody level was not associated with risk of mortality or severity (risk for mortality: OR=3.8; CI=0.78-18.6; P=0.1; I2: 32.3; severity: OR=1.74; CI=0.96-3.16; P=0.07). Evidence currently available is insufficient for a quantitative analysis of autoantibodies association with long COVID-19. Anti-IFN measurement should be considered in COVID-19 follow-up. In a population-based rational, optimized vaccination strategies should be considered for individuals with anti-IFN antibodies since it could represent a risk for a worse prognosis. High-quality prospective studies for short- and long-term disease effects and autoantibody evaluation are still needed.

New onset of giant cell arteritis with ischaemic optic neuropathy following the seventh dose of COVID-19 mRNA vaccination: A case report and literature review

Coronavirus disease (COVID-19) vaccines have demonstrated excellent efficacy in reducing the morbidity and severity of the disease. However, some patients have been reported to develop systemic rheumatic diseases, such as rheumatoid arthritis, myocarditis, Guillain-Barre syndrome, and giant cell arteritis (GCA) following COVID-19 vaccination. We present a case of GCA with ischaemic optic neuropathy following COVID-19 mRNA vaccination. A 73-year-old woman developed headache, myalgia, scalp tenderness, and jaw claudication 4 days after her seventh dose of the vaccination; she also developed severe visual disturbances 1 month after the vaccination. The blood examination tests showed an increased serum C-reactive protein level and erythrocyte sedimentation rate. The echogram for the temporal artery showed a halo sign. Ophthalmic examination revealed ischaemic optic neuropathy in both eyes. The patient was treated with a high-dose glucocorticoid and tocilizumab under the diagnosis of GCA with ischaemic optic neuropathy, obtaining mild improvement of the symptoms. This report underscores the need for clinical vigilance and further data collection regarding GCA cases after COVID-19 vaccination.

Elderly-onset inflammatory myopathy associated with Sjögren's syndrome following SARS-CoV-2 vaccination

As vaccination against SARS-CoV-2 has progressed, various autoimmune diseases, including inflammatory myopathies, have been reported to develop after vaccination. Sjögren's syndrome (SS) sometimes presents as extra-glandular manifestations including inflammatory myopathy. In this report, we describe a case of inflammatory myopathy associated with SS that occurred in an atypically elderly patient after receiving the first dose of the SARS-CoV-2 mRNA vaccine (BNT162b2). The inflammatory myopathy was pathologically classified into non-specific myositis and characterised by predominant infiltration of the B cell lineage in this case. Combined treatment with glucocorticoid, intravenous immunoglobulin, and immunosuppressant resulted in an improvement in swallowing function and muscle strength. While we recognise the efficacy and safety of SARS-CoV-2 vaccines, we also emphasise the importance of recognising that individuals with an immunogenetic predisposition such as positivity of anti SS-A antibody may show disease activity including inflammatory myopathy following vaccination in SS, even at an atypically old age.

Autoimmune-Like Hepatitis Related to SARS-CoV-2 Vaccination: Towards a Clearer Definition

Vaccines are the most effective tool against COVID-19 and are generally safe. Very rare and heterogeneous cases of acute liver injury associated to all types of SARS-CoV-2 vaccines have been reported, mostly with autoimmune features. Epidemiological studies used heterogeneous diagnostic criteria and included different populations. Immunological studies in selected cases of acute liver injury linked to mRNA SARS-CoV-2 vaccines suggest that it has a unique pathophysiology, the vaccine-encoded spike protein playing a central role in triggering the aberrant immune response. In most series, liver injury was observed more often following the second vaccine dose. Latency from vaccination to the diagnosis of hepatitis was 1-147 days after the last vaccine dose. Raised immunoglobulin G levels and positive anti-nuclear and/or anti-smooth muscle antibodies are frequent. The vast majority of reported cases have been treated with corticosteroids, mostly associated with azathioprine. Outcome is generally favourable, but cases requiring liver transplantation or causing death have been reported. The heterogeneous clinical entity of acute liver injury linked to SARS-CoV-2 vaccines includes patients requiring long-term immunosuppression, similarly to autoimmune hepatitis, and patients with self-limiting liver damage, possibly representing a unique form of autoimmune-like hepatitis, which we suggest being referred to as SARS-CoV-2 vaccine-associated liver injury (SVALI). Further studies are needed to investigate the pathogenic mechanisms related to the immune response to the spike viral protein in the liver.

The Immune System, An Arrow into the Heart. Principles of Cardioimmunology, An Emerging Branch in Medicine

Cardioimmunology is an emerging branch of medicine whose development has been facilitated by more sophisticated diagnostic procedures. Recent studies have mainly focused on the immune response during myocardial infarction (MI), and there is evidence that both resident and external immune cells participate in acute inflammatory disease, as well as tissue remodeling. Following MI, macrophages, dendritic cells (DCs) and mast cells (MCs) are the main players in the heart. Under steady-state conditions, cardiac resident macrophages (CRMs) protect the heart against stress and infectious events, being involved in cell and matrix turnover, as well as phagocytosis of apoptotic cells. Moreover, CRMs contribute to the resolution of inflammation via release of interleukin (IL)-10, and efferocytosis of dying cells. Conversely, CCR2+ monocytederived macrophages promote inflammation in the acute phase of myocardial damage, with the release of pro-inflammatory cytokines. Conventional (c) DCs possess enhanced capacity to present antigens to T lymphocytes. In MI patient autopsies, massive infiltration of T helper (Th) cells and CDs has been detected in the myocardium. Cardiac MCs play a dual role during MI, with the production of cytokines for early inflammatory response, and the release of anti-inflammatory cytokines, IL10 and IL-13 during the resolution phase. In experimental coronary artery ligation, the myocardium is infiltrated with Th1, Th2, Th17, and T regulatory (TREG) cells, which participate in the acute inflammation. In cardiac repair, T cell reparative response is mediated by TREG cells, with improved ventricular remodeling and function post-ischemia. In this review, emphasis will be placed on the innate and adaptive immune response during and post-MI. At the same time, immunotherapy- based cardiac failure following chimeric antigen receptor T-cell and immune checkpoint inhibitory therapy will be pointed out.

Impact of COVID-19 on the prevalence of oral and maxillofacial disorders: A retrospective cohort study

ObjectiveThe COVID-19 pandemic has impacted various health conditions. Emerging evidence suggests that COVID-19 may trigger or exacerbate oral and maxillofacial conditions, yet data from Iraq and the broader Middle East remain limited. This retrospective cohort study, conducted at the Laboratory of Oral Pathology, College of Dentistry, University of Baghdad, explores potential links between COVID-19 infection and maxillofacial disorders.MethodsThis was a retrospective cohort study using data from the Laboratory of Oral Pathology, College of Dentistry, University of Baghdad. Cases were divided into pre-COVID-19 and post-COVID-19 periods. Chi-square tests assessed differences in oral pathologies incidence, while logistic regression analyzed associations with COVID-19 status and corticosteroid use.ResultsMucormycosis cases demonstrated a significant increase from 3 (pre-COVID-19) to 23 (post-COVID-19), with 65.22% of post-COVID-19 patients testing COVID-19-positive. A significant increase in mucormycosis severity was observed after COVID-19 (χ² = 14.24, p = 0.0026). Logistic regression identified age (coefficient 0.8738) as having a significant association with severe mucormycosis, while COVID-19 status (coefficient 0.1272) exerted a lesser effect. Sjögren's syndrome increased from 15 to 25 cases, with a model area under the curve of 0.8, indicating substantial ability to distinguish symptom changes pre- vs. post-COVID-19.ConclusionThe findings suggest that the pandemic has considerably impacted the incidence and severity of mucormycosis and Sjögren's syndrome. Older age and COVID-19 positivity may be key drivers of severe mucormycosis, whereas COVID-19 infection appeared to exacerbate Sjögren's syndrome symptoms. These results underscore the importance of vigilant monitoring and targeted therapeutic strategies for managing oral and maxillofacial conditions during and after viral pandemics.

COVID-19 vaccines and blood glucose control: Friend or foe?

PURPOSE

To overview the recent literature regarding the relationship between COVID-19 vaccines and glycemic control.

METHODS

Data were extracted from text and tables of all available articles published up to September 2023 in PubMed Database describing glucose homeostasis data in subjects exposed to COVID-19 vaccines, focusing on patients with diabetes mellitus (DM).

RESULTS

It is debated if the immune system impairment observed in diabetic patients makes them susceptible to lower efficacy of vaccines, but evidence suggests a possible improvement in immune response in those with good glycemic control. Despite their proven protective role lowering infection rates and disease severity, COVID-19 vaccines can result in diabetic ketoacidosis, new-onset diabetes, or episodes of hyper- or hypoglycemia.

CONCLUSIONS

Evidence with COVID-19 vaccines highlights the strong relationship existing between DM and immune system function. Clinicians should strive to achieve optimal glucose control before vaccination and promptly manage possible glucose homeostasis derangement following vaccine exposure.

Evaluation of post-COVID mortality risk in cases classified as severe acute respiratory syndrome in Brazil: a longitudinal study for medium and long term

Background

There are few studies in the literature evaluating post-COVID mortality in Brazil, along medium and long term, especially in those who presented severe clinical disease.

Objective

This study aims to investigate the factors associated with post-COVID mortality of severe acute respiratory syndrome (SARS) cases from 2020 to 2023 in Brazil, along medium and long term.

Methods

Retrospective cohort study using notification data of SARS classified as COVID-19 from the Brazilian National Information System, "Sistema de Vigilância Epidemiológica (SIVEP)," during the period 2020 to 2023. Data included demographics, comorbidities, vaccination status, number of COVID-19 vaccine doses, city of residence, and survival outcomes. Classic Cox, Cox mixed effects, and Cox fragility models were used to assess medium and long-term risks of dying post-COVID.

Results

In the medium and long-term periods studied, 5,157 deaths were recorded out of 15,147 reported SARS/COVID-19 cases. Of these deaths, 91.5% (N = 4,720) occurred within the first year, while 8,5% (N = 437) after the first year. People without formal education, the older adult, had higher percentages of deaths in both periods. In the medium-term post-COVID period, the risk of death was reduced by 8% for those who had been vaccinated while in the long-term post-COVID period, the risk of death almost doubled for those who had been vaccinated. While in the medium term, there was a reduction in mortality risk for those who took two or three doses, in the long term the risk of death was greater for those who took one or two doses.

Conclusion

The protective effect of COVID-19 immunization was observed up to one year after the first symptoms. After one year, the effect was reversed, showing an increased risk of death for those vaccinated. These results highlight the need for further research to elucidate the factors that contribute to these findings.

Post-COVID-19 Vaccination and Long COVID: Insights from Patient-Reported Data

INTRODUCTION

COVID-19 vaccinations reduce the severity and number of symptoms for acute SARS-CoV-2 infections and may reduce the risk of developing Long COVID, also known as post-acute sequelae of SARS-CoV-2 (PASC). Limited and heterogenous data exist on how these vaccinations received after COVID-19 infection might impact the symptoms and trajectory of PASC, once persistent symptoms have developed.

METHODS

We investigated the association of post-COVID-19 vaccination with any SARS-CoV-2 vaccine(s) on PASC symptoms in two independent cohorts: a retrospective chart review of self-reported data from patients (n = 128) with PASC seen in the Stanford PASC Clinic between May 2021 and May 2022 and a 2023 multinational survey assessment of individuals with PASC (n = 484).

FINDINGS

Within the PASC Clinic patient cohort (n = 128), 58.6% (n = 75) were female, and 41.4% (n = 53) were male; 50% (n = 64) were white, and 38.3% (n = 49) were non-white. A total of 60.2% (n = 77) of PASC Clinic patients reported no change in their PASC symptoms after vaccination, 17.2% (n = 22) reported improved symptoms, and 22.7% (n = 29) reported worsened symptoms. In the multinational survey cohort (n = 484), 380 were from the U.S., and 104 were from outside the U.S.; 88.4% (n = 428) were female, and 11.6% (n = 56) were male; and 88.8% (n = 430) were white, and 11.2% (n = 54) were non-white. The distribution of survey self-reported vaccine effects on PASC symptoms was 20.2% worsened (n = 98), 60.5% no effect (n = 293), and 19.2% improved (n = 93). In both cohorts, demographic features, including age, sex, and race/ethnicity, were not significantly associated with post-vaccination PASC symptom changes. There was also a non-significant difference in the median dates of COVID-19 infection among the different outcomes. BMI was significant for symptom improvement (p = 0.026) in the PASC Clinic cohort, while a history of booster doses was significant for symptom improvement (p < 0.001) in the survey cohort.

CONCLUSIONS

Most individuals with PASC did not report significant changes in their overall PASC symptoms following COVID-19 vaccinations received after PASC onset. Further research is needed to better understand the relationship between COVID-19 vaccinations and PASC.

Autoantibodies Targeting G-Protein-Coupled Receptors and RAS-Related Molecules in Post-Acute COVID Vaccination Syndrome: A Retrospective Case Series Study

Background/Objectives: While post-acute COVID-19 syndrome is well known and extensively studied, the post-acute COVID vaccination syndrome (PACVS) is a more recent nosological entity that is poorly defined at the immunopathological level, although it shares many symptoms with the sequelae of viral infections. Methods: This single-center retrospective study reports a case series of 17 subjects vaccinated with mRNA or adenoviral vector vaccines who were healthy before vaccination and had never been infected with SARS-CoV-2 but who presented with symptoms similar to PACVS for a median time of 20 months (min 4, max 32). The medical records of all patients referred to our outpatient clinic over a one-year period were retrospectively analyzed. Results: In this group, serological tests showed that, in addition to positivity for anti-spike protein antibodies, a high percentage of subjects were positive for antibodies against G protein-coupled receptors and molecules involved in the response to SARS-CoV-2. In a panel of 16 autoantibodies tested, a few were positively associated with some of the symptoms reported by patients: anti-ATR1 with lymphadenopathy and/or tonsillitis; anti-ACE2 with skin symptoms such as ecchymosis, skin oedema, and rash; anti-MAS1 with widespread burning sensation; and anti-STAB1 with skin oedema and rash. Anti-ADRA2A were negatively associated with memory loss and/or mental fog. ACE2 correlated with the serum levels of anti-S antibodies, supporting the hypothesis of an anti-idiotype mechanism in the immunopathogenesis of PACVS. Conclusions: This exploratory analysis suggests that the levels of autoantibodies directed against ACE2, and probably also MAS1 and STAB1, may serve as biomarkers for PACVS.

Pemphigus and Bullous Pemphigoid Following COVID-19 Vaccination: A Systematic Review

The COVID-19 pandemic has encouraged the rapid development and licensing of vaccines against SARS-CoV-2. Currently, numerous vaccines are available on a global scale and are based on different mechanisms of action, including mRNA technology, viral vectors, inactive viruses, and subunit particles. Mass vaccination conducted worldwide has highlighted the potential development of side effects, including ones with skin involvement. This review synthesizes data from 62 manuscripts, reporting a total of 142 cases of autoimmune blistering skin diseases (AIBDs) following COVID-19 vaccination, comprising 59 cases of pemphigus and 83 cases of bullous pemphigoid. Among the 83 bullous pemphigoid cases, 78 were BP, with additional cases including 2 oral mucous membrane pemphigoid, 1 pemphigoid gestationis, 1 anti-p200 BP, and 1 dyshidrosiform BP. The mean age of affected individuals was 72 ± 12.7 years, with an average symptom onset of 11 ± 10.8 days post-vaccination. Notably, 59% of cases followed vaccination with BNT162b2 (Pfizer-BioNTech), 51.8% were new diagnoses, and 45.8% occurred after the second dose. The purpose of our review is to analyze the cases of pemphigus and bullous pemphigoid associated with COVID-19 vaccination and to investigate the pathogenetic mechanisms underlying the new development or flare-up of these diseases in association with vaccination. Our results show that the association between COVID-19 vaccines and AIBDs is a possible event.

The Post-Acute COVID-19-Vaccination Syndrome in the Light of Pharmacovigilance

Background/Objectives: Clinical studies show that SARS-CoV-2 vaccination sometimes entails a severe and disabling chronic syndrome termed post-acute-COVID-19-vaccination syndrome (PACVS). PACVS shares similarities with long COVID. Today, PACVS is still not officially recognised as a disease. In contrast, long COVID was registered by health authorities in December 2021. Here, we address possible reasons for that discrepancy. Methods: We analyse whether common symptoms of PACVS have been registered by European pharmacovigilance as adverse vaccination reactions and which consequences have been drawn thereof. Results: (i) PACVS is distinguished from normal vaccination reactions solely by prolonged duration. (ii) Symptom duration is poorly monitored by post-authorisation pharmacovigilance. (iii) PACVS-specific signals were faithfully recorded by pharmacovigilance systems but have not prompted appropriate reactions of health authorities. (iv) The most widely applied SARS-CoV-2 mRNA-vaccine has been modified after roll-out without renewed phase III evaluation; the modification has increased DNA contaminations suspected to extend the spectrum of adverse events. (v) Crossing of pharmacovigilance data with corresponding estimates of applied vaccine doses suggest a PACVS prevalence of 0.003% in the general population. In contrast, occupational surveillance studies suggest a PACVS prevalence of 0.9% in young and middle-aged persons. Conclusions: (a) Denial of official recognition of PACVS is unjustified. (b) PACVS seems to target preferentially young and middle-aged persons. (c) Without official disease recognition, access to public healthcare and welfare services is made difficult for PACVS-affected persons, which creates considerable socio-economic problems. (d) Without official disease recognition, development and evaluation of PACVS therapies is impaired.

Increased incidence of Graves' disease during the COVID-19 pandemic in children and adolescents in the United States

Introduction

Reports in adults indicate that Severe Acute Respiratory Syndrome Corona Virus-2 (SARS-CoV-2) infection and vaccination trigger the expression of autoimmune disease such as Graves' disease, but the incidence of new onset Graves' disease and its temporal relationship to the peaks of COVID-19 cases in children are unclear.

Methods

This is a retrospective study of children and adolescents with new-onset Graves' disease diagnosed between September 2017 and August 2022, N=156, mean age of 12.5 ± 4 year (y), with a range of 2.9-17.9y. There were 119 female (76.3%) and 37 male (23.7%) subjects. Subjects were categorized into 2 groups: pre-COVID-19 era Graves' disease (n=63, age 12.5 ± 3.3y), and COVID-19 era Graves' disease (n=93, age 12.4 ± 4.4y). We calculated incidence rate based on new cases of Graves' disease and total number of new patient referrals to our endocrine clinic. We first compared the demographic, clinical and biochemical data between the above 2 groups; and also, between subjects with either a history of COVID-19 infection (n=23) or vaccination (n=17) to a control group (n=63).

Results

The incidence of Graves' disease was significantly higher during the pandemic: pre-COVID-19 versus the COVID-19 era, n=55, 0.56% vs n=93, 0.9%, p=0.005, after accounting for the total number of annual new patient referrals during the study period. The rise in the cases of Graves' disease followed the spikes in the number of cases of COVID-19 in NY. There was also a statistically significant difference in the race distribution between the pre-COVID-19 and the COVID-19 era (p=0.026).

Discussion

The incidence of Graves' disease increased significantly in children living in New York during the COVID-19 pandemic. The temporal relationship between the peaks of COVID-19 cases and the increased cases of new onset Graves' disease suggest possible autoimmune triggering by SARS-CoV-2.

Clinical Manifestation of Alopecia Areata After COVID-19 Infection or Vaccination

BACKGROUND

Alopecia areata (AA) is characterized by an autoimmune inflammatory response to hair follicles. Several studies have suggested that infection and vaccination can trigger an autoimmune process around hair follicles. Moreover, reports of AA and various other autoimmune diseases have increased since the coronavirus disease 2019 (COVID-19) pandemic became established.

OBJECTIVE

We assessed the clinical characteristics and treatment response in patients who developed AA following COVID-19 infection or vaccination.

METHODS

This retrospective study involved patients who had developed COVID-19 or received a COVID-19 vaccination within 3 months before the onset or aggravation of AA from January 2020 to December 2022.

RESULTS

Fifty patients met the inclusion criteria. Eighteen patients had a history of COVID-19 infection, and 32 had a history of COVID-19 vaccination. The mean onset of AA after COVID-19 infection and vaccination was 5.22±3.35 and 4.13±2.73 weeks, respectively. The most common COVID-19-associated symptoms before AA were fever (88.9%) in the infection group and myalgia (50.0%) in the vaccination group. In the vaccination group, AA most commonly occurred after receiving the Pfizer-BioNTech vaccine (BNT162b2, 46.9%) or Moderna vaccine (mRNA-1273, 34.4%). The vaccination group showed more rapid improvement than the infection group; however, both showed significant improvement after 6 months of treatment of AA.

CONCLUSION

We examined the clinical characteristics and treatment responses of patients who developed AA after COVID-19 infection or vaccination. Further research is needed to evaluate the detailed pathogenesis and association between COVID-19 and AA.

ASIA syndrome after BNT162b2 vaccination: Is it a distinct rheumatoid arthritis phenotype?

Vaccines are an identified cause of autoimmune/inflammatory syndrome induced by adjuvants (ASIA syndrome). In this research, we aimed to investigate the remarkable features of patients, whom we classified as ASIA syndrome, developing rheumatoid arthritis (RA) after BNT162b2 vaccination. Patients who were asymptomatic before the BNT162b2 vaccination, developed chronic arthritis within 3 months after the vaccination, and fulfilled the 2010 American College of Rheumatology/European League Against Rheumatism RA classification criteria were enrolled in the study. Demographic, laboratory, clinical, and treatment characteristics were reviewed retrospectively. We identified ten patients developing RA following BNT162b2 vaccination. The median age was 54.5 years and six of them were female. The median time between vaccination and onset of symptoms was 7 days; seven patients had acute arthritis, and four had intermittent arthritis at the onset of the disease. Only three patients had a disease onset in the small joints of the hands. All patients had radiological erosions on hand X-rays. We reported a case series of patients, classifiable as having ASIA syndrome, who developed RA with radiological erosions after the BNT162b2 vaccine. The onset of the disease in joints different from the typically expected ones, along with the early development of erosions in hand X-rays, suggests that these cases may follow a course distinct from classic RA. RA that develops following mRNA vaccination may have an aggressive course, but studies with larger sample sizes are needed.

Pituitary and COVID-19 vaccination: a systematic review

PURPOSE

This systematic review aims to examine the latest research findings and assess the impact of COVID-19 vaccination on the pituitary gland.

METHOD

PubMed and Tripdatabase were searched from January 1st, 2020 to February 12th, 2024. Case reports, case series and reviews related to post COVID-19 vaccination pituitary disease were included. Eligible articles were tabulated and analysed in the attempt to provide an overview on the epidemiology, clinical presentation, imaging, treatment, outcomes and pathophysiological background of post COVID-19 vaccination pituitary disease.

RESULTS

Among the 23 case reports included in this review, post COVID-19 vaccination hypophysitis was reported in 9 patients, pituitary apoplexy (PA) in 6 cases, SIADH in 5 cases and Isolated ACTH deficiency in 2 cases. Additionally, precipitating adrenal crisis was registered in 7 patients and pituitary tumor enlargement in 1 patient after receiving COVID-19 vaccination.

CONCLUSION

Despite the rarity of these events, our research findings suggest an association between COVID-19 vaccination and the subsequent development of pituitary diseases. The most common manifestations include hypophysitis with ADH deficiency, PA and SIADH, with symptoms typically emerging shortly after vaccine administration. Potential pathogenetic mechanisms include molecular mimicry, vaccine adjuvants and vaccine-induced thrombotic thrombocytopenia (VITT), with the presence of ACE2 receptors in the hypothalamus-pituitary system contributing to the process. These findings can aid in diagnostic and treatment decisions for patients presenting with these syndromes. Nevertheless, given the rarity of these events, safety and efficacy of the currently available COVID-19 vaccines remain robust and we strongly advocate continuing pursuing vaccination efforts.

Aplastic Anemia in the light of the COVID-19 pandemic: infection, vaccination, and pathophysiologic mechanisms

Patients infected with SARS-CoV-2 and vaccinated against COVID-19 could develop aplastic anemia (AA). Comprehensive review and analysis were conducted through a selective literature search in PubMed, Scopus, EMBASE, and Web of Science. For this analysis, 26 studies were included, comprising 16 case reports, 7 case series, and 3 observational studies, totaling 53 patients. The causes of acquired or idiopathic AA are diverse; this review presents recent findings, including possible new etiologies such as SARS-CoV-2 infection and COVID-19 vaccines. This possible association is explored, addressing the existing gap, and aiming to improve daily medical practice. This article reviews the relationship between AA and SARS-CoV-2 infection, as well as COVID-19 vaccines, analyzing cases of de novo occurrence and relapses of AA. Although a definitive mechanistic link has not yet been established, possible underlying pathophysiological mechanisms are explored.

The WHO Algorithm for Causality Assessment of Adverse Effects Following Immunization with Genetic-Based Anti-COVID-19 Vaccines: Pitfalls and Suggestions for Improvement

Clarifying and differentiating the causes of diseases is an essential step in any clinical activity, but it takes on particular relevance and complexity in the case that arise following vaccinations. The WHO has proposed a protocol that uses a list of specific questions about vaccine-related adverse events and an algorithm for making a judgement. Here, we analyze and discuss the important limitations of this protocol when applied to the new genetic-based anti-COVID-19 vaccines, particularly once dealing with rare and unexpected pathological events. The main controversial aspects concern: (a) the prevailing consideration of other possible causes; (b) the biological plausibility and the choice of an appropriate time window to consider adverse effects possibly caused by vaccines; (c) the reference to scientific literature, which may be very limited and often controversial in early stages of introducing new vaccines because of the short period of observation; (d) the final classification of the algorithm into only three classes, which leaves ample space for the "indeterminate" category. Failure to address these issues may lead to distorted pharmacovigilance reports with significant consequences on the benefit/harm assessment. In anticipation of possible future pandemics managed with new vaccines, the WHO algorithm needs to be revised with appropriate protocols for monitoring and evaluation of adverse effects that take into account the novel mechanism of action and real-world epidemiological data.

Global Burden of Vaccine-Associated Chronic Urticaria, 2010-2023: From the Global Pharmacovigilance Database

PURPOSE

The etiology and pathophysiology of vaccine-associated chronic urticaria (CU) remain unclear, particularly during the coronavirus disease 2019 (COVID-19) pandemic. Thus, this study aimed to comprehensively investigate the global burden and long-term trends of vaccine-associated CU, with a focus on the associated vaccines and the distribution of cases across different age groups and sexes.

METHODS

Using data from the World Health Organization international pharmacovigilance database (VigiBase), which encompasses reports from 156 countries and territories between 1968 and 2023, we systematically analyzed the global burden and long-term trends in vaccine-associated CU reports (total individual case safety reports = 131,255,418). We estimated the global and regional reports, information component (IC) with IC0.25 using disproportionality analyses, and reporting odds ratio (ROR) with 95% confidence interval (CI) to investigate the potential associations between 27 vaccines and CU.

RESULTS

Among the 3,474 reports of all-cause CU, 1,898 vaccine-associated CU reports were identified between 2010 and 2023. A dramatic surge in vaccine-associated CU reports has been observed since 2020, primarily driven by the COVID-19 mRNA vaccines. The COVID-19 mRNA vaccines were associated with the most CU reports (ROR, 26.52 [95% CI, 24.33-28.90]; IC, 3.18 [IC0.25, 3.10]), followed by papillomavirus (ROR, 4.23 [95% CI, 2.55-7.03]; IC, 1.93 [IC0.25, 1.06]), influenza (ROR, 3.09 [95% CI, 2.16-4.43]; IC, 1.57 [IC0.25, 0.96]), Ad5-vectored COVID-19 (ROR, 2.82 [95% CI, 2.40-3.31]; IC, 1.42 [IC0.25, 1.16]), and zoster vaccines (ROR, 2.28 [95% CI, 1.32-3.93]; IC, 1.12 [IC0.25, 0.18]). These increased risks were particularly pronounced for males and older adults. No fatal outcomes have been reported in vaccine-associated CU.

CONCLUSIONS

This study underscores the importance of clinicians considering the potential risk factors associated with vaccine-associated CU, especially in the context of COVID-19-related vaccines. Ongoing pharmacovigilance efforts facilitated by robust reporting systems are required to further validate our findings.

Outcomes of Covid-19 Vaccine-Associated Glomerular Diseases (CVAGD) - A Case Series from India

Background

Several cases of glomerular diseases following Covid-19 vaccination, especially mRNA vaccines, have been reported. However, there is little data on glomerular diseases associated with the two vaccines widely available in India (Covaxin and Covishield) and their long-term outcomes.

Materials and Methods

This was a prospective observational study conducted between May 2021 and May 2023. Patients with new-onset or relapse of proteinuria, hematuria, or renal failure within 30 days of Covid-19 vaccination were included. Data on pre-existing renal disease, vaccine type, symptomatology, laboratory reports, kidney biopsy findings, and treatment details were collected. The clinical course and long-term renal outcomes were studied.

Results

Sixteen patients with Covid-19 vaccine associated glomerular disease (CVAGD) were studied. The median age was 28 years (IQR 20.5-40) and median time of symptom onset was 14 days (IQR 10-16.5) after vaccination. Renal syndromes at presentation were nephrotic syndrome in seven patients (43.75%), nephritic syndrome in seven patients (43.75%), and rapidly progressive renal failure in two patients (12.5%). Kidney biopsy revealed minimal change disease in five patients (31.2%); IgA nephropathy in four patients (25%); C3 glomerulopathy, lupus nephritis, and focal segmental glomerulosclerosis in two patients each (12.5%); and pauci-immune glomerulonephritis (ANCA-associated vasculitis) in one patient (6.25%). Eleven patients were treated with immunosuppressive drugs. Median duration of follow-up was 20 months (IQR 18-21). At last follow-up, 11 patients had complete recovery of renal failure and proteinuria and 4 patients had partial recovery.

Conclusion

The most common lesions in this series were minimal change disease and IgA nephropathy. The overall long-term outcome of CVAGD appears good.

ASIA Syndrome: State-of-the-Art and Future Perspectives

The expression "Autoimmune/inflammatory syndrome induced by adjuvants (ASIA)" was coined by Shoenfeld and colleagues in 2011. It defines a group of immune-mediated disorders that arise in people, with a genetic predisposition, following exposure to adjuvant agents. This syndrome has been reported after contact with silicone implants, medications, infections, metals, vaccines, and other substances. It typically occurs in individuals with a genetic predisposition, particularly involving genes, such as HLA-DRB1 (major histocompatibility complex, class II, DR beta 1) and PTPN22 (protein tyrosine phosphatase non-receptor type 22). Some stimuli lead to an overactivation of the immune system, prompt the production of autoantibodies, and finally cause autoimmune disorders. This narrative review aims to provide an overview of the ASIA syndrome with a special focus on the role of adjuvants in different vaccines, especially after the COVID-19 pandemic, and insights into development of new treatments.

The Ambivalence of Post COVID-19 Vaccination Responses in Humans

The Coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has prompted a massive global vaccination campaign, leading to the rapid development and deployment of several vaccines. Various COVID-19 vaccines are under different phases of clinical trials and include the whole virus or its parts like DNA, mRNA, or protein subunits administered directly or through vectors. Beginning in 2020, a few mRNA (Pfizer-BioNTech BNT162b2 and Moderna mRNA-1273) and adenovirus-based (AstraZeneca ChAdOx1-S and the Janssen Ad26.COV2.S) vaccines were recommended by WHO for emergency use before the completion of the phase 3 and 4 trials. These vaccines were mostly administered in two or three doses at a defined frequency between the two doses. While these vaccines, mainly based on viral nucleic acids or protein conferred protection against the progression of SARS-CoV-2 infection into severe COVID-19, and prevented death due to the disease, their use has also been accompanied by a plethora of side effects. Common side effects include localized reactions such as pain at the injection site, as well as systemic reactions like fever, fatigue, and headache. These symptoms are generally mild to moderate and resolve within a few days. However, rare but more serious side effects have been reported, including allergic reactions such as anaphylaxis and, in some cases, myocarditis or pericarditis, particularly in younger males. Ongoing surveillance and research efforts continue to refine the understanding of these adverse effects, providing critical insights into the risk-benefit profile of COVID-19 vaccines. Nonetheless, the overall safety profile supports the continued use of these vaccines in combating the pandemic, with regulatory agencies and health organizations emphasizing the importance of vaccination in preventing COVID-19's severe outcomes. In this review, we describe different types of COVID-19 vaccines and summarize various adverse effects due to autoimmune and inflammatory response(s) manifesting predominantly as cardiac, hematological, neurological, and psychological dysfunctions. The incidence, clinical presentation, risk factors, diagnosis, and management of different adverse effects and possible mechanisms contributing to these effects are discussed. The review highlights the potential ambivalence of human response post-COVID-19 vaccination and necessitates the need to mitigate the adverse side effects.