Prolonged angioedema after Pfizer-BioNTech COVID-19 vaccine.

This case reports a woman in her 40s with a history of allergic reaction to shellfish and iodine who presented with tongue angioedema, difficulty breathing and chest tightness after receiving the first dose of the Pfizer-BioNTech (BNT162b2) COVID-19 vaccine. Her angioedema remained for 10 days post-exposure to the vaccine, requiring 3 days of epinephrine infusion. She was discharged with advice to avoid further mRNA vaccines. This case highlights the increasing awareness needed of polyethylene glycol (PEG) allergy and the protracted nature of her reaction. A firm conclusion cannot be reached based on a single case report. More research is needed to understand whether there is a causal relationship between the BNT162b2 vaccine and PEG allergy. Awareness regarding PEG allergy and the complexities associated with it is important and needs to be raised due to its prevalent use in diverse industries.

Optic neuromyelitis after vaccination against SARS-CoV-2.

Neuromyelitis optica is an autoimmune demyelinating astrocytopathy of the central nervous system that primarily affects the optic nerve and spinal cord. It is considered a multifactorial disease associated with antibodies against aquaporin 4, with complement cascade activation and lymphocytic infiltration leading to axonal loss and causing significant morbidity and disability. In addition, cases of inflammatory diseases of the central nervous system have been described after vaccination against SARS-CoV-2, mainly acute disseminated encephalomyelitis. Also, a few cases of neuromyelitis optica spectrum disorder, mostly aquaporin 4+, have been reported. We describe a patient who developed symptoms suggestive of acute disseminated encephalomyelitis the next day after vaccination against SARS-CoV-2. Three months later, a longitudinally extensive transverse myelitis compatible with aquaporin 4+ neuromyelitis optica was successfully treated with an interleukin 6 inhibitor. There is no proven association and research is needed to establish whether optic neuromyelitis is related to vaccination; this is a single case report from which no conclusion can be drawn.

Kikuchi-Fujimoto-like lymphadenopathy following COVID-19 vaccine: diagnosis and management.

A woman in her mid 40s presented for breast imaging after 1 week of painful and enlarged right axillary lymphadenopathy. She denied history of fever, weight loss, night sweats fatigue, cat scratch or other trauma. She received the second dose of Pfizer COVID-19 vaccine 3 months previously on the contralateral arm. A mammogram demonstrated a single, asymmetric, large and dense right axillary lymph node. Ultrasound confirmed a 2.5 cm lymph node with cortical thickening of 0.6 cm. Ultrasound-guided core biopsy showed necrotising lymphadenitis with associated aggregates of histiocytes and plasmacytoid dendritic cells. Potential causes of necrotising adenitis including Bartonella, tuberculosis, Epstein-Barr Virus, herpes simplex virus, systemic lupus erythematosus and lymphoma were excluded. In the absence of any identifiable infectious or autoimmune causes, and given the temporal relatedness with vaccine administration, it was determined that the Kikuchi-Fujimoto-like necrotising lymphadenitis was likely secondary to the COVID-19 vaccine. To date, there has been no casual association made between the COVID-19 vaccine and KFD necrotising lymphadenitis.

Early riser specific immune cell response by delayed-type hypersensitivity in a kidney transplant patient vaccinated against COVID-19.

We present a female kidney transplant patient under conventional immunosuppression therapy. Her humoral immunity study (anti-spike-specific antibodies) was negative after the initial regimen and the third dose of vaccination against COVID-19. The specific ex vivo cellular immune study against spike of SARS-CoV-2 by interferon gamma release assay (IGRA) also remained at non-response levels at different time points despite an optimal non-specific cell immune response assessment. However, the cellular immunity test by delayed-type hypersensitivity (DTH) with spike of SARS-CoV-2 was always positive since the vaccination scheme began. Only after COVID-19 infection has there been a seroconversion of the patient's antibody tests along with IGRA positivity. The use of DTH test to measure the immune response could be a better and earlier parameter of the actual immune status that helps us to predict the immune response in real life. Hybrid immunity combining vaccine and natural infection could be a stronger stimulator of the specific global immune response.

A Case of Adult Multisystem Inflammatory Syndrome Following COVID-19 Vaccine.

Multisystem inflammatory syndrome is a life-threatening condition associated with elevated inflammatory markers and multiple organ injury. A diagnosis of exclusion, it has been reported after severe acute respiratory syndrome coronavirus 2 infection (SARS-CoV-2) in children and adults; recently it has been described in some post-COVID-19 vaccinated individuals. The prognosis with supportive care and immunomodulatory therapy is good, although some individuals may require treatment in the intensive care unit (ICU). Here we report a case of a 58-year-old man who developed multi-organ failure after receiving the second dose of the Moderna mRNA-1273 COVID-19 vaccine. He required critical organ support in the ICU. An extensive workup was done to rule out alternative infectious and inflammatory processes. Following a period of gradual in-hospital convalescence, our patient made a full recovery. To our knowledge, this is the first comprehensively described case of multisystem inflammatory syndrome associated with Moderna mRNA-1273 COVID-19 vaccine in an adult over 50 years of age.

Transient cryoglobulinaemic vasculitis following ChAdOx1 nCoV-19 vaccine.

Cryoglobulinaemic vasculitis is an immune-complex-mediated, systemic inflammatory syndrome usually involving small-to-medium vessels due to precipitation of cryoglobulins at <37°C. It can involve any organ but most commonly affects the skin. Associated conditions include infections (hepatitis C and HIV), haematological disorders (chronic lymphocytic lymphoma, monoclonal gammopathy of uncertain significance and multiple myeloma), autoimmune conditions (systemic lupus erythematosus and Sjogren syndrome) or as a complication following vaccination (influenza, pneumococcal and hepatitis B vaccines). Biochemical hallmarks include detection of serum cryoglobulin with low C4 levels. We describe a case of previous healthy patient with transient cryoglobulinaemic vasculitis after first dose of ChAdOx1 nCoV-19 vaccine (AstraZeneca/Oxford).

Case of adult-onset Kawasaki disease and multisystem inflammatory syndrome following SARS-CoV-2 vaccination.

Kawasaki disease (KD) and multisystem inflammatory syndrome (MIS) are rare conditions that occur predominately in children. Recent reports document KD and MIS in adult patients following infection with SARS-CoV-2. Rarely, MIS is observed following vaccination against SARS-CoV-2, mostly in patients with prior SARS-CoV-2 infection. We report a case of KD in a man after a second SARS-CoV-2 vaccine dose, in absence of concurrent or prior SARS-CoV-2 infection. This patient also met criteria for probable MIS associated with vaccination. He tested negative for SARS-CoV-2 RNA via reverse transcriptase PCR, negative for SARS-CoV-2 nucleocapsid antibodies and demonstrated high levels SARS-CoV-2 spike protein antibodies, commonly used to assess vaccine response. Symptom improvement followed treatment with intravenous immunoglobulin, including desquamation of the hands and feet. As widespread vaccination against SARS-CoV-2 continues, increased vigilance and prompt intervention is necessary to limit the effects of postvaccination inflammatory syndromes.

Case of reactive sacroiliitis possibly induced by an mRNA coronavirus disease vaccine.

A woman in her 30s received a second dose, first booster, Corminaty vaccine against the SARS-CoV-2. Three days later, the patient developed unilateral sacroiliitis. A pelvic scan revealed inflammatory joint edges, bone erosion and a heterogeneous mass of 2.5 cm in the psoas muscle. Joint puncture revealed no microcrystalline deposits, but bone marrow cells, erythroblast were identified. The standard bacterial cultures and culture for mycobacteria were negative. HLA B27 was negative, and no seroconversion was identified for HIV, Epstein-Barr virus, cytomegalovirus, chlamydia or Quantiferon. Two months later, the sacroiliitis resolved.The aetiologic approach of this erosive unilateral acute sacroiliitis in a person naïve to rheumatologic pathology was negative for inflammatory or infectious sacroiliitis. Arthralgias after vaccination are expected. Arthritis is less common, and acute sacroiliitis has not yet been described. Acute sacroiliitis may be considered a reactive sacroiliitis to the anti-COVID-19 mRNA vaccine.

Severe myopericarditis following the third dose of an mRNA COVID-19 vaccine: utility of a multimodal treatment approach.

We report a rare case of severe myopericarditis in a healthy man in his 20s after the third dose of an mRNA COVID-19 vaccine. His symptoms and troponinemia resolved with a beta-blocker in addition to standard anti-inflammatory therapy, highlighting the utility of multimodal therapy.

Vaccine-induced immune thrombocytopaenia and thrombosis (VITT) after COVID-19 vaccination.

COVID-19 represents a global health emergency, causing significant morbidity and mortality. Multiple vaccines have been distributed worldwide to control the spread of this pandemic. Several reports of thrombosis and thrombocytopaenia have been described after vaccination. These have been termed vaccine-induced immune thrombocytopaenia and thrombosis (VITT). We report a fatal case of VITT after receiving the first dose of Ad26.COV2.S vaccine. A man in his 30s developed thrombocytopaenia, massive haemoperitoneum due to spleen rupture and extensive portal and femoral vein thrombosis. The patient rapidly developed multiple organ failure and died. We attributed this condition to the vaccine due to the temporal relationship, presence of thrombosis and thrombocytopaenia, high levels of platelet factor 4 antibodies and exclusion of other diagnoses. Healthcare providers should be aware of such rare but fatal complications of COVID-19 immunisation, as early diagnosis of VITT may improve prognosis by allowing timely appropriate treatment.

Acute interstitial nephritis after COVID-19 vaccination.

A woman in her 70s presented to the hospital being generally unwell 8 days following the first dose of the AstraZeneca COVID-19 vaccination. She was in stage III acute kidney injury (AKI) with hyperkalaemia and metabolic acidosis. Urinalysis showed haematoproteinuria. Renal immunology screen was negative. She subsequently underwent two renal biopsies. The second biopsy showed features consistent with acute tubulointerstitial nephritis. She was commenced on oral steroids, which led to marked improvement of her renal function.There are reasons why AKI can occur post vaccination such as prerenal AKI from reduced oral intake postvaccination due to feeling unwell or developing vomiting or diarrhoea. Intravenous fluids were given to this patient but with no meaningful improvement in renal function. She developed a possible reaction to the AstraZeneca COVID-19 vaccine, which led to AKI as supported by the interstitial inflammation and presence of eosinophils on renal biopsy.

Non-arteritic anterior ischaemic optic neuropathy (NA-AION) and COVID-19 vaccination.

A woman in her 50s presented with diminution of vision in her left eye (OS) 4 days after COVISHIELDTM vaccination. She had been diagnosed with non-arteritic anterior ischaemic optic neuropathy (NA-AION) of right eye (OD) 8 months earlier. The present episode revealed a best-corrected visual acuity (BCVA) of 20/50 in OD and 20/20 in OS with grade 1 relative afferent pupillary defect. Fundus evaluation showed pale disc in OD and temporal disc oedema in OS. Humphrey's visual field analysis showed incomplete inferior altitudinal defect in OD and a centro-caecal scotoma in OS. Systemic investigations were normal. OS was diagnosed with NA-AION. She was started on oral aspirin 75 mg. At 1-month follow-up, disc oedema of OS had resolved with BCVA maintaining at 20/20. The patient was lost to follow-up later. The relationship between the vaccine and the ocular event is temporal with no causal association.

Management of a severe bilateral pulmonary embolism as a complication of VITT following vaccination with AstraZeneca COVID-19 vaccine.

Since the start of vaccination against COVID-19 viral infection using adenovirus-based vector vaccine (eg, The Oxford-AstraZeneca vaccine, using the modified chimpanzee adenovirus ChAdOx1, and the Johnson & Johnson vaccine, using human adenovirus serotype 26), a rare, but potentially life-threatening complication called vaccine-induced thrombotic thrombocytopenia (VITT) was reported. As the number of cases increases every day, with the increase in the number of vaccinated people all over the world, this complication is a concern to the medical field. We report a case on the acute management of a patient who presented to us with life-threatening bilateral pulmonary embolism as a complication of VITT after the first dose of vaccination with Oxford-AstraZeneca vaccine against COVID-19.

Recrudescence of severe polyneuropathy after receiving Pfizer-BioNTech COVID-19 vaccine in a patient with a history of eosinophilic granulomatosis with polyangiitis.

A middle age man with a history of diabetes mellitus type 2, hypertension, migraine and eosinophilic granulomatosis with polyangiitis (EGPA) with polyneuropathy in remission presented with paresthesia and motor weakness soon after receiving the Pfizer-BioNTech COVID-19 messanger RNA (mRNA) vaccine. The patient had polyneuropathy 10 years ago secondary to EGPA, which had resolved. EGPA was diagnosed on the basis of typical symptoms and positive sural nerve biopsy. Five days after receiving the first dose of COVID-19 vaccine, he developed heaviness and reduced dexterity of both the upper extremities, which progressed to patchy and asymmetric motor weakness of all four extremities. Given the lack of clear alternative explanation after a thorough work up, recrudescence of underlying asymptomatic polyneuropathy due to a possible reaction to COVID-19 mRNA vaccine was considered although a temporal association with vaccine dose does not prove causality. He was treated with corticosteroids with slow improvement of his symptoms.

Vaccine-induced thrombosis and thrombocytopaenia with widespread abdominal venous thrombosis, venous ischaemia and bowel oedema.

A 49-year-old woman presented with severe abdominal pain and per rectal bleed, 13 days after receiving the first dose of the AstraZeneca vaccine. Blood tests showed remarkably low platelet count, unmeasurable D-dimer levels and low fibrinogen levels, consistent with a diagnosis of vaccine-induced thrombotic thrombocytopaenia and disseminated intravascular coagulation. CT mesenteric angiogram revealed massive portosplenic mesenteric vein thrombosis. CT head also noted non-occlusive thrombosis at several sites. She was treated with intravenous immunoglobulins, plasma exchange, anticoagulants and transjugular intrahepatic portosystemic shunt procedure. Following a prolonged inpatient stay, she was discharged with subsequent short bowel syndrome and long-term parenteral nutrition. This particular clinical scenario aims to highlight the importance for clinicians to remain vigilant for rare complications associated with the AstraZeneca vaccine and the subsequent management involved, at a time where it is vital to vaccinate globally in order to control the spread of the COVID-19 pandemic.

Vaccination-associated immune thrombocytopenia possibly due to ChAdOx1 nCoV-19 (Covishield) coronavirus vaccine.

Immune thrombocytopenia (ITP) is an acquired haemorrhagic diathesis of immune-mediated destruction, impaired production or increased splenic sequestration of platelets. It can be idiopathic (primary) or secondary (infections, medications, HIV infection, malignancies, connective tissue diseases or rarely secondary to vaccination). ITP postvaccination is termed vaccine-associated ITP (VITP) and is known to be caused by vaccines against various infectious agents such as measles-mumps-rubella, Haemophilus influenzae, pneumococcus, hepatitis B virus and human papilloma virus. Cases of VITP post SARS-CoV-2 vaccination have also been reported in the literature. Various hypotheses on the occurrence of the same are theorised, but no single theory has been proven to cause VITP conclusively. Management includes routine treatment of ITP with use of agents such as steroids, intravenous immunoglobulins, or on rare occasions a thrombopoietic agent or vinca alkaloids. We present a case of VITP possibly due to ChAdOx1 nCoV-19 (Covishield) vaccination in a middle-aged woman who responded to steroid therapy.

Thrombotic thrombocytopenic purpura following administration of the Moderna booster vaccine.

Thrombotic thrombocytopenic purpura (TTP) is a type of thrombotic microangiopathy that is characterized by microangiopathic haemolytic anaemia, consumption thrombocytopenia and organ injury. It is caused by a severe deficiency of ADAMTS13, which can be either congenital or acquired. There is a plethora of things that can cause the acquired form, including medications and infections. Vaccines have also been shown to cause TTP. In the midst of the COVID-19 pandemic, with multiple new vaccines being developed and distributed to the masses, the medical community needs to be aware of adverse events associated with these new vaccines. We present a case of TTP following administration of the Moderna booster vaccine.

Haemophagocytic lymphohistiocytosis following COVID-19 mRNA vaccination.

The development of vaccinations has been instrumental in the ongoing effort to combat the COVID-19 pandemic. Although the benefits of vaccination are unquestionable, there have been reports of potentially rare life-threatening complications following vaccination including thrombocytopaenia, haemolytic anaemia, vasculitis and myocarditis. Haemophagocytic lymphohistiocytosis (HLH), a rare but life-threatening inflammatory condition, has also been described postadenoviral vector COVID-19 vaccination but it has never been reported post-messenger RNA (mRNA) COVID-19 vaccination. We report two cases of HLH admitted to our hospital after administration of COVID-19 mRNA vaccines. We also searched the vaccine adverse event reporting system and found 50 reports of suspected HLH following COVID-19 vaccination. Presently, we cannot define a causality between COVID-19 mRNA vaccination and HLH development. However, we hope the reporting of our two cases (and additional cases seen in the adverse event reporting database) will help us determine whether there is a potential relationship. Prompt recognition of this condition is of utmost importance to initiate life-saving therapy.

Systemic capillary leak syndrome (SCLS) after receiving BNT162b2 mRNA COVID-19 (Pfizer-BioNTech) vaccine.

Systemic capillary leak syndrome (SCLS), also known as Clarkson's disease, is a rare disorder of unknown aetiology. Since SCLS was first described in 1960, fewer than 500 cases have been reported. SCLS is diagnosed by the classic triad of hypotension, haemoconcentration and hypoalbuminaemia resulting from fluid extravasation. Some reports show that SCLS may sometimes occur as a side effect of adenoviral vector COVID-19 vaccines, although there is only one report (two cases) of SCLS after receiving a messenger RNA vaccine. Survival rates for SCLS are very poor without treatment, so it is crucial for clinicians to recognise this disorder. A middle-aged woman who presented with generalised malaise and anasarca after receiving the BNT162b2 COVID-19 vaccine was diagnosed with SCLS. Treatment with methylprednisolone and intravenous immunoglobulin was commenced and her symptoms resolved. We expect that this case report will add to the existing literature on this rare disorder and the side effects of vaccinations.

Guillain-Barre syndrome (GBS) associated with COVID-19 infection that resolved without treatment in a child.

A 9-year-old boy presented with unbalanced gait, back pain and lower limb weakness. His physical examination revealed almost absent lower limbs reflexes and cerebro-spinal fluid (CSF) showed albuminocytologic dissociation. The brain and spine MRI with contrast illustrated abnormal enhancement-suggestive of Guillain-Barré syndrome.The case had limited distribution and it did not progress beyond the presenting clinical involvements. They did not need immunotherapy, self-recovered, managed conservatively using painkillers and gabapentin along with physiotherapy-with a wait and see approach. The child is now almost back to normal after 8-12 weeks.