Case Report: ANCA-Associated Vasculitis Presenting With Rhabdomyolysis and Pauci-Immune Crescentic Glomerulonephritis After Pfizer-BioNTech COVID-19 mRNA Vaccination

Abstract

As the coronavirus disease 2019 (COVID-19) pandemic is ongoing and new variants of severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) are emerging, there is an urgent need for COVID-19 vaccines to control disease outbreaks by herd immunity. Surveillance of rare safety issues related to these vaccines is progressing, since more granular data emerge with regard to adverse events of COVID-19 vaccines during post-marketing surveillance. Interestingly, four cases of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) presenting with pauci-immune crescentic glomerulonephritis (GN) after COVID-19 mRNA vaccination have already been reported. We here expand our current knowledge of this rare but important association and report a case of AAV presenting with massive rhabdomyolysis and pauci-immune crescentic GN after Pfizer-BioNTech COVID-19 mRNA vaccination. As huge vaccination programs are ongoing worldwide, post-marketing surveillance systems must continue to assess vaccine safety important for the detection of any events associated with COVID-19 vaccination. This is especially relevant in complex diseases where diagnosis is often challenging, as in our patient with AAV presenting with massive rhabdomyolysis and pauci-immune crescentic GN.

Case Report: Anti-neutrophil Cytoplasmic Antibody-Associated Vasculitis With Acute Renal Failure and Pulmonary Hemorrhage May Occur After COVID-19 Vaccination

“…Prior cases have been mainly reported among elderly individuals without known renal diseases. Six cases have been associated with a mRNA vaccine, while a viral vector vaccine has been associated with two cases (8)(9)(10)(11)(12)(13)(14). AAV was diagnosed after either the first dose (37.5%) or second dose (62.5%) of COVID-19 vaccination.…”

“…AAV was diagnosed after either the first dose (37.5%) or second dose (62.5%) of COVID-19 vaccination. The onset time of symptoms varied from <1 week to 7 weeks (8)(9)(10)(11)(12)(13)(14). While non-specific prodromal symptoms were observed after vaccination, characteristic findings included microscopic or gross hematuria with dysmorphic red blood cells, significant proteinuria, and acute renal failure (8)(9)(10)(11)(12)(13)(14).…”

“…The onset time of symptoms varied from <1 week to 7 weeks (8)(9)(10)(11)(12)(13)(14). While non-specific prodromal symptoms were observed after vaccination, characteristic findings included microscopic or gross hematuria with dysmorphic red blood cells, significant proteinuria, and acute renal failure (8)(9)(10)(11)(12)(13)(14). Serum creatinine levels ranged from 1.9 to 8.4 mg/dL (8,(10)(11)(12)(13)(14).…”

“…Serum creatinine levels ranged from 1.9 to 8.4 mg/dL (8,(10)(11)(12)(13)(14). Extra-renal involvement with pulmonary hemorrhage, necrotic masses, consolidations and rhabdomyolysis were observed in four cases (9,13,14). Although a range of different therapeutic treatments were reported, most patients exhibited improvements in renal function and pulmonary symptoms; however, one patient (serum creatinine level, 8.4 mg/dL) required dialysis due to irreversible renal damage (Table 1).…”

De-Novo Antineutrophil Cytoplasmic Antibody-Associated Vasculitis Following the mRNA-1273 (Moderna) Vaccine for COVID-19

“…There are few reports of ANCA-associated vasculitis following COVID-19 vaccination [4][5][6][7][8][9]. However, only two cases of de-novo anti-proteinase (PR3) ANCA-associated pauci immune glomerulonephritis are reported after the mRNA-1273 (Moderna) COVID-19 vaccine to date [8,9].…”