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The increasing report of new autoimmune inflammatory rheumatic diseases (AIRD) that appears after COVID-19 vaccination is great concern. Here, we described a case report of a patient who developed thrombotic microangiopathy de novo after COVID-19 vaccination.
Case Description: A female 79-year-old, presented generalized edema, non-productive cough and dyspnea for at least seven days after receiving the COVID-19 vaccine. Furosemide was administered with improvement of symptoms. Two months later, she presented polyarthralgia with positive rheumatoid factor, burning pain in the palms and soles accompanied by distal weakness compatible with sensory motor axonal polyneuropathy. Chest CT scan showed a diffuse pulmonary fibrosis. Treatment was started with Hydroxychloroquine, Methotrexate and Prednisone.
She was hospitalized due to a fall from standing heigh by instability. She presented worsening dyspnea, and an increment in generalized edema. On examination, she was afebrile with a regular pulse of 115 bpm, respiratory rate of 29 bpm, SatO2 of 82% on room air, and blood pressure of 179/107 mmHg. She showed diffuse crackles, with bilateral basal predominance. Her extremities showed thickened skin, distal coldness and multiple erythematous lesions on fingers. She preserved sensitivity; however, bilateral leg strength was estimated 3/5 power, with presence of distal edema 2/4. She had edematous and erythematous polyarthralgias (elbows, knees, carpometacarpals, metacarpophalangeals, interphalangeals).
Laboratory evaluation showed creatinine of 5.2 mg/dl, urea of 135 mg/dl, hypoalbuminemia of 3 mg/dl, dysmorphic erythrocyturia, albuminuria/creatinuria index of 3736 mg/g, and proteinuria/index creatinuria of 6.6 g/g. She presented anemia without evidence of hemolysis in peripheral blood smear (Hb 8.1g/dL, LDH 382 mg/dl, direct coombs negative, platelets 206000/L). Autoimmune results were Low C3, Normal C4, ANA positive, Anti-DNA negative, Anti-Sm negative, Lupus anticoagulant negative, Antiphospholipid negative, Anti-Ro positive, Anti-La positive, Anti-Scl70 positive, ANCA c and ANCA p negative. HIV, Hepatitis Virus B and C were ruled out. Thus, she was diagnosed with Mixed Connective Tissue Disease.
Due to her kidney failure and nephrotic syndrome, a renal biopsy was performed. This study showed thrombotic microangiopathy. It presented proliferative membrane pattern, thrombi in preglomerular vessels and fibrinoid necrosis (figure 1). The arteries had marked narrowing of lumen and myxoid degeneration of the intima (figure 2 & 3). Immunofluorescence was negative. Due to fluid overload and progression to anuria, dialysis treatment was started. Moreover, three boluses of methylprednisolone of 500 mg and cyclophosphamide 500 mg were administered. The patient suffered from upper digestive bleeding and pulmonary sepsis. In few days, she passed away.
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Mass COVID-19 vaccination was a fundamental tool to overcome the health emergency. However, growing report of cases of de novo autoimmune pathologies post-vaccination, the morbidity and mortality should be considered when recommendation of vaccination schedule are developed.