ABSTRACT
Background: The world is currently rocking to and fro in the midst of the COVID-19 viral storm and vaccinations have played a pivotal role in calming this.Although COVID-19 vaccines have been thoroughly assessed and studied before being rolled out to the general population, there have been reports of post vaccination complications in limited number of subjects strongly associated with COVID-19 vaccinations[1]. Objectives: To report a case of severe ANCA associated vasculitis after COVID-19 vaccination. Methods: A case report and discussion. Results: In view of this, we report the case of a 77 year old caucasian male who developed severe ANCA associated vasculitis (AAV) after two doses of Astra-Zeneca vaccine and one booster dose of Pfzer COVID-19 booster. He presented with acute onset infammatory arthritis with mononeuritis multiplex with bilateral foot drop and left radial and ulnar nerve forearm weakness in typical asymmetrical pattern two weeks after the Pfzer vaccination. He had a raised MPO-ANCA titre of 66 IU/ml, C-reactive protein of 131mg/L and reactive thrombocytosis of 458 X 10 9/L. Nerve conduction study confrmed mononeuritis multiplex in the bilateral peroneal nerves and left radial and ulnar nerve. A total body CT had excluded malignancy and paraneoplastic associations and Gullian-Barre diagnosis was also excluded. The patient was treated with 3 days of intravenous methylprednisolone 1g daily then given intravenous Rituximab 1g, two weeks apart. He is currently undergoing rehabilitation in view of the vasculitic neuropathy from his diagnosis. Conclusion: Diagnosis of AAV is often delayed or missed by other medical specialties due to its varied presentation. AAV should be suspected in a patient with paraesthesia/weakness in keeping with mononeuritis multiplex or other peripheral neuropathy in the absence of an alternative explanation (e.g. diabetes,B12 defciency) and in particular with a wrist or foot drop.Exposure to certain drugs and substances of abuse such as cocaine, hydralazine and propylthiouracil has been implicated with AAV.While short-term side effects of COVID-19 vaccine resemble those of other vaccines, long-term side effects remain unknown[2]. Rare side effects continue to surface as millions of people receive COVID-19 vaccines around the world.
ABSTRACT
Case report-IntroductionPanniculitides comprise a heterogeneous group of inflammatory diseases involving the subcutaneous fat. They remain the most challenging areas for clinicians. Skin biopsy is commonly needed to confirm diagnosis. Because there are many underlying aetiologies for panniculitis, detailed history and thorough investigations are needed. We present a case of A 20-year male who was admitted with painful lumps treated initially as cellulitis/abscess but turned to be neutrophilic panniculitis on skin biopsy. Extensive workup failed to reveal underlying aetiology. Eventually Imradli (AntiTNF) was thought to be the culprit and therefore was kept on hold with no recurrence of panniculitis.Case report-Case descriptionA 20-year-old, Asian Malawian. Moved to the UK at the age of 6. He was diagnosed with Ankylosing spondylitis in November 2016. Initially received Naproxen followed by (Humira) with good clinical response. He was switched to biosimilar Imradli in Nov 2019. He was admitted with 2-3 weeks history of progressive right hip and buttock pain, 1 week of very tender erythematous swelling of the right buttock but without fever or weight loss. He reported mild weakness of lower limbs. Physical examination revealed 5x 8 cm swelling on Right buttock, Rest of examination was unremarkable. He was reviewed by neurology team who arranged MRI spine and brain, EMG and lumbar puncture which all came back as unremarkable excluding the possibilities of myelitis and myositis. Initially thought to be abscess/cellulitis but absence of fever/inflammatory response, abnormal CT finding and no response to antibiotics made it less likely. While the Right buttock erythema/swelling started to resolve, he developed two new migratory erythematous lesions appearing around the left buttock and lower lumbar spine. Working diagnosis of panniculitis was made which was confirmed on biopsy. Due to lack of response to NSAIDs, colchicine or oral steroids, a 3rd biopsy of the freshest lesion was performed to exclude deep-seated infection.Investigations-FBC, U&ES, LFT, CRP, CK, ACE-all were unremarkableASO titre <200, serology for Borrelia and TPHA negative.Viral, parasitic, and Autoimmune screen were unremarkable.CXR clear, MRI/CT: extensive subcutaneous inflammatory changes in the right buttock with sacral oedema.PET-CT-showed resolving inflammatory changes in the right flank, FDG intake in C6 and SI joints presumed secondary to ankylosing spondylitis and sacroiliitis.The underlying cause of panniculitis remains uncertain. Anti TNF was kept on hold and the patient was followed up with no evidence of recurrence of panniculitisCase report-DiscussionPanniculitis (inflammation of subcutaneous fat) is a relatively uncommon condition. It has various aetiologies including infection, trauma, inflammation, and malignancy. Skin biopsy can give valuable information including microbiological studies if infectious panniculitis was suspected. However, clinical correlation and careful consideration of the differential diagnosis is needed in many cases.The diagnosis can be quite challenging as in this case where all investigations and skin biopsy could not point towards the underlying aetiology. Although anti-TNF inhibitors are commonly used in treating a wide range of autoimmune conditions. But their use can lead to the development of secondary autoimmune diseases, such as cutaneous vasculitis, lupus-like syndrome, and interstitial lung disease, paradoxically induced by anti-TNF-a agents. Llamas-Velasco and Requena, reported the first case of panniculitis induced by etanercept injection in a 62-year-old woman with severe psoriasis who developed an erythematous, slightly painful nodule on the skin of the anterior abdominal wall.Adalimumab induced lupus panniculitis was reported in a Rhu-lupus patient. Although the lesions stopped progressing after cessation of adalimumab, they remained unchanged for two more years. The mechanism for adalimumab-induced CLE is uncertain.Although there is not enough data about autoimmunity with biosimilars, we think seco dary autoimmune conditions could similarly be induced by biosimilar as illustrated in this case. Anti-TNF induced cutaneous panniculitis is considered most likely although uncertain. If anti-TNF drug-induced, this should gradually resolve but can be slow (4-6 months). Corticosteroids have been added for an anti-inflammatory response, but there was little benefit which might point to a different pathogenetic mechanism.NSAIDs has helped to keep his AS relatively stable during the COVID-19pandemic. During the last review, the patient expressed his wishes to go back on biologic. But the question remains whether he will a have a recurrence of panniculitis or not?Case report-Key learning points1/Anti-TNF inhibitors sometimes cause secondary autoimmune conditions like cutaneous vasculitis, lupus-like syndrome, but there is not enough data regarding biosimilar induced autoimmunity.2/This case illustrates the high importance of having a tissue diagnosis. (whenever there is an issue, the diagnosis would be in the tissue).3/There is still uncertainty whether a recurrence of panniculitis might occur or not if the patient went again on biologics.
ABSTRACT
Case report-IntroductionBased on initial clinical data, it was suggested that patients with vasculitis who were immunosuppressed, would have a more severe COVID-19 infection. Here we present a case of a young 26-year old lady with granulomatosis with polyangiitis (GPA) on rituximab who developed COVID-19 infection while on active GPA treatment. Her COVID-19 infection confirmed on PCR serology, has been protracted but non-fulminant. She did not require mechanical respiratory support. At the same time her GPA remained active and worsened requiring further immunosuppression after she developed mild pulmonary haemorrhage. She is currently still receiving vasculitis treatment.Case report-Case descriptionA 26-year-old lady with a background history of obstructive sleep apnoea and fibromyalgia was diagnosed with ENT-limited GPA in 2017. She was initially treated with azathioprine then methotrexate, and later switched to Rituximab in 2018 after she developed organ-threatening manifestations with bilateral hearing loss. She was stable on periodic infusions of rituximab at 6 to 9-monthly intervals and did not develop other organ-threatening features.She had been given one dose of rituximab for a flare of her GPA. In between rituximab doses, she was admitted with acute COVID-19 infection with related pneumonia and treated with antibiotics, fluids, and oxygen. Shortly after discharge, she was readmitted with worsening symptoms of non-resolving COVID-19 pneumonia which was evident on chest X-ray and levofloxacin treatment was initiated. Her condition improved and she was discharged. No mechanical respiratory support was required. She had her 2nd dose of rituximab after it had been delayed by about 2 weeks. She had been afebrile after the acute COVID-19 infection and her persistent positive results were explained as related viral shedding over a period of 8 weeks.One week later, she represented to hospital with fever, cough and shortness of breath, and her blood results showed a remarkable rise in inflammatory markers, including a CRP of 242. She was treated for non-resolving COVID-19 pneumonitis with worsening chest X-ray features. After hospital discharge, her GPA continued to flare with persistent epistaxis with nasal crusting. She also had worsening inflammatory arthritis with purpuric rash on her legs. An ENT review confirmed nasal septum perforation, but no renal involvement was found. Additional cyclophosphamide was commenced via the day-case unit. Her SARS-CoV-2 serology was negative prior to commencing cyclophosphamide. She is now SARS-CoV-2 positive after two doses of cyclophosphamide, but she is afebrile and stable.Case report-DiscussionCOVID-19 infection carries a high mortality rate in patients with multiple co-morbidities, but recent literature suggests that patients on immunosuppressants may not actually have fulminant COVID-19 disease. This case illustrates the challenges of treating active vasculitis in the context of ongoing COVID-19 infection. Her vasculitis remained active requiring escalation of immunosuppression with caution, while she was concomitantly fighting SARS-CoV-2 and superadded bacterial infection. A similar case has been published by Guilpain et al of a 52-year-old woman with PR3-ANCA vasculitis on maintenance therapy with rituximab and low-dose prednisone who developed COVID-19 infection. They reported milder evolution of COVID-19 infection in comparison with previous reports.It is now well known that some disease-modifying anti-rheumatic drugs (DMARDs) such as tocilizumab, hydroxychloroquine and tofacitinib could suppress the cytokine profile seen in severe COVID-19 infection. In addition, several case reports have even reported possible protective effect of immunosuppressants against severe complications of COVID-19 in patients with rheumatological and non-rheumatological conditions. Another complexity in this case was monitoring the disease progression, since both COVID-19 and GPA can have similar findings on chest CT scan of ground glass opacity. In order to better understand the role of imm nosuppressants in rheumatological patients with COVID-19 infection, more data is required, currently European League Against Rheumatism (EULAR) is collecting data to monitor and report outcomes of COVID-19 in adult and paediatric population, this will provide invaluable insight for Rheumatologists. Case report-Key learning points This case poses a challenge for Rheumatologists in managing a patient with active vasculitis and concomitant COVID-19 infection due to limited data available literature. It has also stressed the importance of working in a multidisciplinary team when managing such complex patients. Importance of continuous surveillance of patients receiving immunosuppressive therapy is advised due to possible increased risk to SARS-CoV-2.
ABSTRACT
Background/AimsDue to the COVID-19 pandemic there have been changes to NHSservices to limit unnecessary patient hospital visits and comply withnew social restriction rules. One of these changes has been theintroduction of virtual consultations in outpatient clinics to replacetraditional face to face appointments.MethodsA retrospective analysis of patient feedback from adult outpatientvirtual appointments in a 4-month period was collated and reviewed(May-September 2020). After an appointment, patients were sent atext message asking for feedback. The text consisted of one mainquestion asking patients to rate their experience and a commentsection. The data from this brief patient survey was obtained for allrheumatology patient responses. At the end of the text there was a linkfor a more comprehensive online survey which patients could fill out ifthey wish to provide more detailed feedback. Responses to this surveyencompasses all adult outpatient specialities including musculoskeletal services.ResultsThere were 269 responses to the detailed patient survey from variousadult outpatient clinics. The most common type of virtual consultationwas telephone which was the case in 79%, of which 91% of patientsstated the caller was polite and 89% felt they had an opportunity toask questions. When asked what their overall view 43% of patientsstated they would not mind conducting all future appointments viatelephone, 23.5% felt that in the current situation a telephoneconsultation was acceptable but would have preferred a face to faceand 7% were completely unsatisfied. From the musculoskeletal groupthere were 36 responses (20 orthopaedic, 15 rheumatology and 1musculoskeletal). 92% of patients stated they were given the opportunity to ask questions and 86% were satisfied with the advicegiven to them. 33% (n = 12) stated they would not mind having virtualconsultations in the future even after the pandemic, but 28% statedthey would have preferred a face to face consultation. There were 784responses to the shorter patient survey via text message fromrheumatology patients. When asked to rate their experience 94%(n = 739) of patients stated it was either good or very good, and only1% said it was poor or very poor. There were largely positivecomments in the feedback. Most frequent points were patients feltlistened to, communication was good and virtual consultations wereless stressful.ConclusionAt present the use of virtual clinics seems to be well received bypatients and most importantly their quality of care is not compromised.From a patient's perspective there are many benefits and cumulativefeedback so far suggests that majority of the patients are willing toadapt to this new approach to outpatient appointments both now andpost-COVID-19.