Neurological autoimmune diseases following vaccinations against SARS-CoV-2: a case series
Neurological autoimmune diseases following vaccinations against SARS-CoV-2: a case series
Abstract
Background and purpose
Population-based studies suggest that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines may trigger immune-mediated thrombotic thrombocytopenia (VITT) raising concerns for other autoimmune responses. The aim was to characterize neurological autoimmunity after SARS-CoV-2 vaccinations.
Methods
In this single-centre prospective case study patients with neurological autoimmunity in temporal association (≤6 weeks) with SARS-CoV-2 vaccinations and without other triggers are reported. Clinical, laboratory and imaging data were collected with a median follow-up of 49 days.
Results
In the study period 232,603 inhabitants from the main catchment area of our hospital (Rhein-Neckar-Kreis, county) received SARS-CoV-2 vaccinations. Twenty-one cases (new onset n = 17, flares n = 4) diagnosed a median of 11 days (range 3–23) following SARS-CoV-2 vaccinations (BNT162b2 n = 12, ChAdOx1 n = 8, mRNA-1273 n = 1) were identified. Cases included VITT with cerebral venous sinus thrombosis (n = 3), central nervous system demyelinating diseases (n = 8), inflammatory peripheral neuropathies (n = 4), myositis (n = 3), myasthenia (n = 1), limbic encephalitis (n = 1) and giant cell arteritis (n = 1). Patients were predominantly female (ratio 3.2:1) and the median age at diagnosis was 50 years (range 22–86). Therapy included administration of steroids (n = 15), intravenous immunoglobulins in patients with Guillain–Barré syndrome or VITT (n = 4), plasma exchange in cases unresponsive to steroids (n = 3) and anticoagulation in VITT. Outcomes were favourable with partial and complete remissions achieved in 71% and 24%, respectively. Two patients received their second vaccination without further aggravation of autoimmune symptoms under low-dose immunosuppressants.
RESULTS
During the inclusion phase of our study, 5978 patients (inpatient N = 1204, outpatient N = 4774, vaccination status not available for review) were treated at our department. In the same interval an estimated 232,603 inhabitants from the Rhein-Neckar county (population 547,625), the main catchment area of our hospital, were vaccinated against SARS-CoV-2. Numbers and types of vaccine doses administered are provided in Table 1.
| Type of vaccine | First dose (N, overall) | Second dose (N, overall) | Estimated second dose only (N) | Estimated vaccinated individuals (N) |
|---|---|---|---|---|
| BNT162b2 | 141,884 | 80,449 | 13,138 | 155,022 |
| ChAdOx1 | 51,730 | 6686 | 2405 | 54,135 |
| mRNA-1273 | 19,630 | 15,590 | 1486 | 21,116 |
| Ad26.COV2.S | 2330 | N/A | 2330 | 2330 |
| Total | 215,574 | 102,725 | 17,029 | 232,603 |
- Abbreviation: N, number.
Twenty-one cases of neurological autoimmune responses (new onset n = 17, disease flares n = 4) in temporal association with SARS-CoV-2 vaccinations (BNT162b2 n = 12, ChAdOx1 n = 8, mRNA-1273 n = 1) were identified. The majority of patients (n = 16) including 14 cases of newly diagnosed neurological autoimmunity resided in the Rhein-Neckar county. Sixteen cases were noted following the first dose (BNT162b2 n = 7, ChAdOx1 n = 8, mRNA-1273 n = 1) whereas five cases occurred after the second BNT162b2 dose.
The spectrum of autoimmunity following SARS-CoV-2 vaccinations is depicted in Figure 1a. Conditions—newly diagnosed according to international standards—included VITT with subsequent CVST (n = 3), central nervous system (CNS) demyelinating diseases (n = 6: optic neuritis n = 4; partial transverse myelitis n = 2), inflammatory peripheral neuropathies (n = 4: GBS n = 2, L5 radiculitis n = 1, facial palsy n = 1), myositis (n = 2), limbic encephalitis (n = 1) and giant cell arteritis (GCA) (n = 1). All cases of VITT (n = 3) and GBS (n = 2) occurred in ChAdOx1 recipients whereas all cases of newly diagnosed optic neuritis (n = 4) and myositis (n = 2) followed vaccination with BNT162b2. Flares occurred in patients with multiple sclerosis (n = 2), distal symmetric PM/Scl-75-positive myositis (n = 1) and myasthenia (n = 1). Two patients with known multiple sclerosis (MS) were under ongoing immunosuppressive treatment when they received their SARS-CoV-2 vaccination. Five patients (24%) from this series suffered from additional autoimmune conditions outside the nervous system and a positive family history for autoimmunity was noted in seven patients (33%).
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