Immune transcriptome and antibody response in adult-onset Still's disease with mild flare following administration of mRNA vaccine BNT162b2.

Abstract

Dear Editor, Adult-onset Still’s disease (AOSD) patients represent a population for which vaccination can induce disease flare [1], and little is known about the efficacy of coronavirus disease 2019 (COVID-19) vaccination in this group. The COVID-19 pandemic vaccination programs presented these patients and their healthcare providers with a critical decision as the safety and efficacy of the vaccination are of equal importance. Previously it has been described that AOSD patients can experience disease flare with COVID-19 vaccination [1–6] but no one has yet reported their immune transcriptional and antibody response. Here we present both safety and efficacy information on a 58-year-old male after vaccination who experienced a mild AOSD flare following second BNT162b2 vaccine. The clinical course, immune transcriptional response, and anti-spike antibody titres and neutralization activity were profiled following vaccination. The patient was diagnosed with AOSD in 2013 when he developed classical symptoms following Frühsommer-Meningoenzephalitis (FSME) vaccination against tick-borne encephalitis. Treatment with prednisolone showed good efficacy and symptoms resolved after 3 months. In fall 2020 the patient suffered from another AOSD flare after receiving an influenza vaccination, manifesting as the systemic inflammation AOSD phenotype with lymph node swellings, myalgia, cervicalgia and recurrence of skin lesions from underlying psoriasis, but no synovitis. The disease flare was treated with prednisolone, which was gradually reduced and phased out in August 2021. The patient was infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in early March 2020 with symptoms limited to a mild sore throat and a cough. At the time of COVID-19 vaccination the patient was not receiving any immunosuppressive therapy. In fall 2021 the patient received two BNT162b2 vaccines separated by 4 weeks. Mild symptoms of AOSD started about 2 days after the second vaccination, characterized by myalgia, fever and fatigue with slightly elevated CRP and IL-1 levels measured. The patient was treated symptomatically with non-steroidal medications and the disease flare symptoms were attenuated. However, 3 months post-vaccination the patient still experienced myalgia in both thighs, which is managed with symptom-based application of non-steroidal antirheumatics.