A case of Churg-Strauss vasculitis after hepatitis B vaccination

New insights of antineutrophil cytoplasmic antibody-associated vasculitis from the perspective of COVID-19 vaccination

The occurrence of antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) has been reported since the coronavirus disease 2019 (COVID-19) vaccination, but whether there is a causal relationship or coincidence remains to be verified. We combined the term COVID-19 vaccination with each word of AAV to search for case reports and case series published in PubMed, EMBASE, and Web of Science databases before 13 March 2023. A total of 56 patients who developed AAV after COVID-19 vaccination were identified from 44 research centers. Of the 56 subjects, 43 (76.7%) were vaccinated with the mRNA vaccine, followed by the adenovirus vaccine (14.3%) and inactivated vaccine (9.0%) (P = 0.015). Compared with relapsed AAV, new-onset AAV patients had at least two other diseases previously (P < 0.001). Twenty-five (44.6%) patients presented symptoms after the first injection, and the medium onset time was 12 (1-77) days, while Twenty-eight (50.0%) patients developed symptoms after the second dose, and their medium period was 14 (1-60) days. Forty-four (78.5%) patients achieved remission after immunosuppressive agents, plasma exchange, and hemodialysis. One (1.8%) patient died from progressive respiratory failure and nine (16.1%) did not recover, leaving five patients permanently dependent on hemodialysis. Pathogenic ANCA may be activated by enhanced immune response and epitope spreading after COVID-19 vaccination and induced the occurrence of AAV, especially in genetically susceptible populations.

Eosinophilic Granulomatosis with Polyangiitis: Experiences in Korean Patients

Eosinophilic granulomatosis with polyangiitis (EGPA) is one form of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis. Identical to what has been called Churg-Strauss syndrome, EGPA exhibits both allergic and vasculitis features. EGPA was first described as a syndrome consisting of asthma, fever, eosinophilia, and organ involvement including heart failure, neuropathy, and kidney damage, by Churg and Strauss in 1951. On the basis of the 2012 Chapel Hill Consensus Conferences Nomenclature of Vasculitis, EGPA comprises three typical allergic components, including asthma, peripheral eosinophilia, and eosinophil-rich granuloma of the respiratory tracts. EGPA has three clinical and histological stages. The first is an allergic stage composed of asthma and sinusitis, and the second is an eosinophilic stage characterised by peripheral hypereosinophilia and intra-organ infiltration of eosinophils. The last is a vasculitic stage, including necrotising inflammation of small vessels and end-organ damage. In this review, we describe the classification criteria for EGPA and recommendations for the evaluation and management of EGPA with conventional and newly suggested drugs for EGPA. Also, we discuss a variety of clinical aspects such as predictive values for prognosis and associations with other Th2-mediated diseases and hepatitis B virus.

HBsAg-negative and anti-HBc-positive in eosinophilic granulomatosis with polyangiitis: a retrospective pilot study

We examined whether resolved hepatitis B virus (HBV) infection was associated with antineutrophil cytoplasmic antibody-associated vasculitis (AAV), and affected AAV activity at diagnosis and prognosis during the follow-up. We reviewed the electronic medical records of 153 AAV patients, and included 91 hepatitis B surface antigen (HBsAg)-negative patients having results of both antibody to hepatitis B core antigen (anti-HBc) and surface antigen (anti-HBs). We collected clinical and laboratory data, Birmingham vasculitis activity score (BVAS) and five factor scores (FFS) at diagnosis and relapse rates during the follow-up. We divided patients into the two groups according to the presence of anti-HBc and compared variables between them in patients with AAV or those with each variant. The mean age and follow-up duration were 59.8 ± 15.2-year-old and 48.0 ± 47.5 months. Fifty patients (54.9%) had anti-HBc, and 61 patients (67.0%) had anti-HBs. Only thirty-six (39.6%) patients had ever experienced relapse after remission. There were no remarkable differences between HBsAg-negative AAV patients with and without anti-HBc. However, in eosinophilic granulomatosis with polyangiitis (EGPA) patients, patients with HBs-negative/anti-HBc-positive (resolved HBV infection) showed the higher initial mean BVAS and FFS (2009) than those without. Patients having anti-HBc exhibited significantly increased risk of relapse of EGPA than those having not (RR 16.0). Also, EGPA patients with HBs-negative/anti-HBc-positive showed meaningfully lower cumulative relapse-free survival rates than those without during the follow-up duration (p = 0.043). In conclusion, resolved HBV infection may importantly influence vasculitis activity at diagnosis and subsequently relapse after remission in EGPA patients.

Eosinophilic Granulomatosis with Polyangiitis (EGPA) and Hepatitis B Infection - A Rare Association

Eosinophilic Granulomatosis with Polyangiitis (EGPA) or Churg-Strauss syndrome is a rare systemic illness which is characterized by necrotizing inflammation of small and medium sized vessels. The prominent features include asthma, eosinophilia, transient pulmonary infiltration and systemic vasculitis. Various triggering factors have been reported as putative aetiological agents of Churg-Strauss syndrome. They include infections, allergic desensitization, vaccinations like hepatitis B and influenza vaccination, cocaine abuse, drugs like leukotriene receptor antagonists and exposure to pigeons. We report a rare case of Churg-Strauss syndrome co-infected with Hepatitis B Virus (HBV). Very few such cases have been reported in the past.

Injection Site Lichenoid Dermatitis Following Pneumococcal Vaccination: Report and Review of Cutaneous Conditions Occurring at Vaccination Sites

Background

Cutaneous dermatoses and malignancies have occurred at the sites of vaccines.

Purpose

To describe a man who developed a lichenoid dermatitis at the pneumococcal vaccine injection site and to review cutaneous dermatoses and malignancies occurring at vaccination sites.

Methods

PubMed was used to search the following terms, separately and in combination: adverse, condition, cutaneous, dermatosis, dermatitis, injection, PCV13, pneumococcal, pneumonia, prevnar, reaction, skin, site, vaccination, and vaccine. All papers were reviewed, and relevant manuscripts, along with their reference citations, were evaluated.

Results

Several vaccines—including bacillus Calmette-Guerin, hepatitis B, influenza, leishmaniasis, meningitis, pneumococcal, smallpox, tetanus (alone and in combination with diphtheria, pertussis, polio, Haemophilus influenza type B or plague and yellow fever), and varicella-zoster—have been associated with post-vaccination site reactions. A 70-year-old male developed a lichenoid dermatitis that occurred at the pneumococcal vaccine injection site within 2 weeks after PCV13 vaccination; the erythematous nodule resolved spontaneously within 9 weeks following immunization.

Conclusions

Dermatoses at the injection sites of vaccines can be granulomatous, immunity-related conditions, infections, lichenoid, neutrophilic, or pseudolymphomatous. Basal cell carcinoma and squamous cell carcinoma are the most common vaccination site-associated malignancies; however, melanoma and sarcomas (dermatofibrosarcoma protuberans, fibrosarcoma, and malignant fibrous histiocytoma) are also smallpox vaccine-related site neoplasms. A cutaneous immunocompromised district that is created by vaccine-induced local immunologic changes is hypothesized to be the pathogenesis of vaccination site reactions.

Eosinophilic granulomatosis with polyangiitis (Churg-Strauss) (EGPA) Consensus Task Force recommendations for evaluation and management

OBJECTIVE

To develop disease-specific recommendations for the diagnosis and management of eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome) (EGPA).

METHODS

The EGPA Consensus Task Force experts comprised 8 pulmonologists, 6 internists, 4 rheumatologists, 3 nephrologists, 1 pathologist and 1 allergist from 5 European countries and the USA. Using a modified Delphi process, a list of 40 questions was elaborated by 2 members and sent to all participants prior to the meeting. Concurrently, an extensive literature search was undertaken with publications assigned with a level of evidence according to accepted criteria. Drafts of the recommendations were circulated for review to all members until final consensus was reached.

RESULTS

Twenty-two recommendations concerning the diagnosis, initial evaluation, treatment and monitoring of EGPA patients were established. The relevant published information on EGPA, antineutrophil-cytoplasm antibody-associated vasculitides, hypereosinophilic syndromes and eosinophilic asthma supporting these recommendations was also reviewed.

DISCUSSION

These recommendations aim to give physicians tools for effective and individual management of EGPA patients, and to provide guidance for further targeted research.

Granulomatous dysimmune reactions (sarcoidosis, granuloma annulare, and others) on differently injured skin areas

Granulomatous disorders are chronic cell-mediated immune responses histologically characterized by collections of macrophages, epithelioid cells, and multinucleated giant cells. This disease spectrum often has an infectious origin, but sometimes neither an infective agent nor an inciting antigenic stimulus can be identified. The skin may be a preferential target for these disorders, especially in the areas that have been damaged by various forms of skin injury (eg, herpetic infections, trauma, thermal or solar burns, vaccinations, tattoos). These damaged skin sites frame the new concept of an immunocompromised cutaneous district (ICD), which defines a skin area with acquired immune dysregulation that can pave the way for the local onset of opportunistic disorders, such as infections, tumors, and granulomatous disorders. Sarcoidosis, granuloma annulare (GA), and forms of granulomatous vasculitis, such as Churg-Strauss syndrome (CSS) and Wegener's granulomatosis (WG), are the most common granulomatous disorders that occur in an ICD and may share common pathogenic mechanisms. Recent studies have found clinical and pathologic overlapping features across noninfectious granulomas. Although no unifying etiology exists, the development of granulomatous processes in the ICD has often been reported and the literature contains various hypotheses to explain it: (1) overactive immune response in a previously injured region with or without loss of immune tolerance; (2) overall reduced immune response; (3) retention of an exogeneous antigen or foreign body; (4) altered neural signaling; and (5) a combination of all the aforementioned processes. T helper cells, T regulatory cells, and macrophages, as well as a number of antigenic proteins, have been identified as potential contributing factors. In addition, a genetic predisposition and an intact systemic immune system are both instrumental for the persistence of local granuloma formation in the ICD.

Churg-Strauss Syndrome: an evolving paradigm

The Churg-Strauss Syndrome is an ANCA-associated vasculitis, an inflammatory multisystem disease with preference to the respiratory tract. Peripheral and tissue eosinophilia are the pathological hallmarks of this condition. The etiopathogenesis is unknown but some cytokines appear to play a central role and could be targets for new therapies.

[Flu vaccine and auto-immune and/or inflammatory diseases]

Patients with systemic inflammatory and/or autoimmune diseases have an increased risk of infections particularly severe influenza infections. Annually vaccination can prevent these infections. Available data about the influenza vaccine in these patients show that, it remains well tolerated and effective even if the antibody response is lower compared to healthy controls. These data encourage to vaccine every year patients with systemic inflammatory and/or autoimmune diseases with influenza vaccine, particularly patients taking immunosuppressant drugs or having respiratory, cardiac or renal chronic diseases according to guidelines. More data are needed about the severity of influenza infection and the efficacy of influenza vaccination in patients with systemic inflammatory and/or autoimmune diseases to improve their vaccine coverage.

Churg-Strauss syndrome following cessation of allergic desensitization vaccination: a case report

Introduction

Churg-Strauss syndrome is a vasculitis of medium to small sized vessels. Diagnosis is mainly clinical with findings of asthma, eosinophilia, rhinosinusitis and signs of vasculitis in major organs.

Case presentation

We present a case of a 19-year-old Persian male who developed signs and symptoms of this syndrome related to hyposensitization treatments for allergy control.

Conclusions

No unifying etiology for the disease can be presented as it is found associated with environmental factors, medications, infections and is even considered a variant of asthma with predisposition to vasculitic involvement. Therefore, it is important to recognize this disease and be aware of underdiagnosis because of emphasis on pathologic evidence. Here, we present a case of allergic desensitization causing Churg-Strauss syndrome in the absence of other known factors.

Churg-Strauss syndrome triggered by hyposensitization to Alternaria fungus

Churg-Strauss syndrome is a systemic vasculitis of unknown ethiology. Exposure to putative triggers have been described. We report a case of Churg-Strauss syndrome developing after specific immunotherapy with Alternaria fungus.

P-ANCA cranial pachymeningitis: a case report

Pachymeningitis is an inflammatory process that thickens the dura mater. This disease has various etiologies including infectious, neoplastic, or autoimmune diseases. We present the case of a patient who developed cranial pachymeningitis with a clinical and biological picture suggestive of a neurological form of vasculitis. A 51-year-old woman developed rhinitis, otitis media, headaches, and deterioration of her condition after a course of recombinant hepatitis B vaccine. After a booster dose of the vaccine, she developed unilateral visual loss and impairment of multiple cranial nerves. Blood analysis showed inflammation and presence of antimyeloperoxidase antineutrophil cytoplasmic antibody (MPO-ANCA). Cranial magnetic resonance imaging (MRI) showed pachymeningitis. A complete remission was obtained with immunosuppressive therapy. The initial clinical presentation and subsequent remission under immunosuppressive therapy were suggestive of a vasculitis with nervous system involvement. Though vasculitis was not proven histologically in this patient, we believe that MPO-ANCA-related autoimmunity provoked the patient's disease as already reported in similar cases. As pachymeningitis is a fibrosing process, early recognition and treatment of an autoimmune etiology, even in the absence of previous pulmonary or renal involvement, is required to prevent definitive neurological impairment.

Kawasaki disease in an infant following immunisation with hepatitis B vaccine

The known association between hepatitis B and vasculitis has been reported in rare cases in adults after hepatitis B vaccination. We here describe a 35-day-old infant who developed Kawasaki disease 1 day after receiving his second dose of hepatitis B vaccine. Although extremely rare, this possible side effect should be noted and further investigated.

Drug-induced vasculitis

Therapeutic agents from virtually every pharmacological class have been implicated in the development of drug-induced vasculitis. Clinical manifestations range from small vessel hypersensitivity vasculitis and leukocytoclastic vasculitis to clinical syndromes indistinguishable from classical systemic forms of vasculitis such as Wegener's granulomatosis, polyarteritis nodosa and Churg-Strauss syndrome (CSS). The exact pathogenic mechanisms involved remain to be elucidated; but both cell-mediated and humoral immunity appear to play important roles. Affected individuals may present with cutaneous involvement alone or life-threatening systemic involvement, which may result in severe and sometimes fatal illness. Since clinical presentation as well as serological and pathological parameters is identical to idiopathic forms of vasculitis, a high index of suspicion is necessary to accurately and expeditiously diagnose drug-induced vasculitis. Withdrawal of the offending agent alone is often sufficient to induce prompt resolution of clinical manifestations, obviating the need for systemic corticosteroids or more powerful forms of immunosuppression.

Postvaccine vasculitis: a report of three cases

INTRODUCTION

Vaccines may be responsible for adverse effects, mainly local fugitive and benign reactions. However, few cases of systemic vasculitis have been described. We report three new cases, suggesting the responsibility of vaccination in starting or reactivating systemic vasculitis.

EXEGESIS

We report two cases in a 64- and a 68-year-old woman with polymyalgia rheumatica and temporal arteritis after influenza and tetanus vaccination respectively, and one case in a 30-year-old man with periarteritis nodosa after hepatitis B vaccination.

CONCLUSION

Knowledge of such complications deserve to be expanded in order to: 1) avoid re-immunisations which are likely to result in more serious consequences; 2) avoid aggravation or reactivation of a vasculitis; and 3) control serology before hepatitis B vaccination in all persons at risk of HBV infection.