Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania.
"Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.
Medicine (Baltimore). 2022 Jun 10;101(23):e29431. doi: 10.1097/MD.0000000000029431.
Since mass-scale severe acute respiratory syndrome coronavirus 2 vaccination, there have been case reports of several immune-mediated reactions, including new-onset and flares of glomerular disorders following immunization with mRNA coronavirus disease 2019 vaccines. Here, we report two cases, the first to our knowledge, of relapsing cryoglobulinemic vasculitis with new-onset severe renal involvement following mRNA coronavirus disease 2019 vaccination.
The relapse of the cutaneous and the new onset of severe renal involvement of cryoglobulinemic vasculitis occurred three weeks after the second dose of the mRNA Moderna coronavirus disease 2019 vaccination and two days after the first dose of mRNA Pfizer coronavirus disease 2019 vaccination in the first and second patient, respectively.
Kidney biopsies were performed. The first pacient's kidney biopsy showed a membranoproliferative pattern of glomerular injury with extensive mesangial and endocapillary hypercellularity, while severe endothelial swelling, loss of fenestrations and widening of subendothelial space were identified by electron-microscopy. The second patient's kidney biopsy was consistent with cryoglobulin associated membrano-proliferative pattern of glomerular injury.
Our patients were managed with a combination of immunosuppressants consisting of corticosteroids, Cyclophosphamide and Rituximab with a favourable outcome at the end of the induction period.
Clinical and immunological response was achieved in both patients after four months of follow-up.
The temporal association of the relapse of the cryoglobulinemic vasculitis to mRNA coronavirus disease 2019 vaccination suggest that the vaccine might have been a trigger for the reactivation of the disease in our cases. This possible association should be acknowledged by physicians in order to provide optimal monitoring and treatment in case of reactivation of the disease post-immunization.
自大规模接种严重急性呼吸综合征冠状病毒 2 疫苗以来，已有几例免疫介导反应的病例报告，包括接种信使核糖核酸冠状病毒病 2019 疫苗后新发和肾小球疾病加重。在此，我们报告了两例首例已知的信使核糖核酸冠状病毒病 2019 疫苗接种后复发冷球蛋白血症性血管炎伴新发严重肾损害的病例。
两名患者均在接种第二剂信使核糖核酸 Moderna 冠状病毒病 2019 疫苗后 3 周和第一剂信使核糖核酸 Pfizer 冠状病毒病 2019 疫苗后 2 天分别出现皮肤复发和冷球蛋白血症性血管炎新发严重肾损害。
进行了肾脏活检。第一位患者的肾脏活检显示肾小球损伤呈膜增生性模式，广泛的系膜和毛细血管内细胞增多，而电子显微镜显示严重的内皮肿胀、窗孔丢失和基板下空间增宽。第二位患者的肾脏活检符合冷球蛋白相关膜增生性肾小球损伤模式。
我们的患者接受了免疫抑制剂的联合治疗，包括皮质类固醇、环磷酰胺和利妥昔单抗，在诱导期结束时取得了良好的结果。
两名患者在随访 4 个月后均获得了临床和免疫反应。
冷球蛋白血症性血管炎的复发与信使核糖核酸冠状病毒病 2019 疫苗接种之间的时间关联表明，疫苗可能是我们病例中疾病复发的触发因素。这种可能的关联应该引起医生的注意，以便在免疫接种后疾病复发时提供最佳的监测和治疗。
