We report a case of adult-onset Still disease (AOSD) after ChAdOx1 nCOV-19/AZD1222 coronavirus disease 2019 (COVID-19) vaccine (AstraZeneca).
A 51-year-old female received her first AZD1222 vaccine in spring of 2021. Within hours, she experienced myalgias and a fever of 39 ºC. After 6 days, she developed a generalized urticarial eruption (Figure 1). She had migratory arthralgia and swelling of elbows, wrists, knees, and ankles. COVID-19 nucleic acid amplification test was negative. She responded to nonsteroidal antiinflammatory drugs but had recurrent intermittent fevers and recurrent transient rash.
Urticarial papules and plaques on the patient’s left medial thigh 6 days after AZD1222 vaccination.
Three months later, she re-presented with rash and tenderness to wrists, left second and third metacarpophalangeal joints, and right knee. There was no lymphadenopathy. She had hyperferritinemia (110,660 [normal 15-247] mcg/L), transaminitis (aspartate transaminase 163 [normal 10-38] U/L, and alanine aminotransferase 64 [normal < 36] U/L), elevated interleukin (IL)-6 (62.6 [normal 0.1-4.9] pg/mL) and IL-18 (1008 [normal 0-127] pg/mL). Computed tomography of the abdomen revealed enlarged aortocaval and para-aortic lymph nodes without hepatosplenomegaly. Autoantibody and infection screens were normal. According to the Yamaguchi criteria for AOSD diagnosis,1 she satisfied 3 of 4 major criteria: fever, arthralgia/arthritis, and typical rash. She met 3 of 5 minor criteria: lymphadenopathy, elevated liver enzymes, and negative antinuclear antibody, and rheumatoid factor. Prednisone and celecoxib treatment led to rapid improvement of arthralgia and rash. Ferritin level trended downward thereafter (Figure 2).
Ferritin and CRP levels at different timepoints after receiving 1 dose of the AZD1222 vaccine. CRP: C-reactive protein.
COVID-19 and AOSD activate similar inflammatory pathways.2,3 There are 3 reported cases of AOSD following AZD1222 vaccination4 and several reports of AOSD following mRNA vaccination.5,6 Ongoing symptomatology after vaccination should prompt consideration of an autoinflammatory disease.
Footnotes
The authors declare no conflicts of interest relevant to this article.
Written informed consent was obtained from the patient for the publication of this report.
- Copyright © 2023 by the Journal of Rheumatology
