Two cases of ulcerative colitis flare following SARS-CoV-2 mRNA vaccination

ABSTRACT

Introduction: The advent of mRNA vaccines has been a major component of the vaccination effort against COVID-19. Immunization with mRNA vaccines has been associated with a systemic inflammatory response.1 We present two cases of patients with ulcerative colitis (UC) in long-term remission who experienced flare following vaccination. Case description/methods: Patient 1 A 50-year-old female with history of UC in remission of 4 years on mesalamine who received both doses of the mRNA-1273 mRNA vaccine, 28 days apart, presented with diarrhea and bloody stools that developed 1 week after dose 1. Patient had worsening diarrhea 1 week following vaccination that progressed to hematochezia. Abdominopelvic CT demonstrated contiguous colitis. She was treated with mesalamine and methylprednisolone. Her symptoms improved in 2 days, and she was discharged on a steroid taper. Patient 2 A 52-year-old female with history of UC in remission of 5 years on mesalamine who received both doses of the BNT162b2 mRNA vaccine, 21 days apart, presented with abdominal pain, diarrhea, and bloody stool that developed 1 day after dose 2. Abdominopelvic CT demonstrated diffuse colitis, and she underwent colonoscopy, which was aborted due to extensive colitis. Sigmoid colon biopsy confirmed crypt abscess formation architectural distortion and ulceration. She was treated with mesalamine and methylprednisolone. Her acute disease was complicated by bowel perforation, and she underwent total colectomy. Discussion: The presence of an environmental trigger is frequently linked to onset of disease flare in patients with UC.2 These two patients were in symptomatic remission on 5-ASA maintenance agents for several years prior to vaccination. The lack of clear alternate environmental changes in these patients suggests provocation of flare by the inflammatory response following vaccination. Existing literature evaluating SARS-CoV-2 mRNA vaccine adverse-events in patients with UC suggests that gastrointestinal side-effects are uncommon.3 In addition, biologic agent use may decrease rate of vaccine-related adverse events.3 Recommendations from an international expert consensus favors vaccination of patients with UC.4 In addition, recent literature demonstrates strong immunologic response following vaccination of patients with UC despite concurrent use of biologic agents.5 Consideration should be given to pre-treatment of patients with UC in remission to decrease risk of flare.