Discussion
Local injection site reactions (swelling, itching, redness, tenderness)
and systemic symptoms (fever, headache, fatigue, chills, myalgias, and
arthralgias) are the most common adverse effects of all type of COVID-19
vaccines. The rare adverse reactions of COVID-19 vaccines like
anaphylaxis, vaccine induced immune thrombocytopenia, thromboembolism
(arterial thrombosis, cerebral venous sinus thrombosis), myocarditis,
pericarditis, and Guillain-Barre-syndrome (3,4). Minimal change disease
is also reported with Pfizer Biotech vaccine (5,6). Despite these
adverse effects, COVID-19 vaccines are safe and effective as documented
by large number of clinical trials.
Johnson & Johnson vaccine is an adenovirus vector vaccine which has
human adenovirus type 26 (Ad26) vector. The vector expresses SARS-CoV-2
spike (S) antigen without virus propagation which elicits immune
response to S antigen providing protection against COVID-19. Thrombotic
complications associated with thrombocytopenia and Guillain-Barre
syndrome are the rare reported adverse effect of Johnson & Johnson
COVID-19 vaccine (7). AAV has been not reported previously as the
adverse reaction of this vaccine. Here, we report a newly onset renal
limited AAV in a 52 year-female after COVID-19 vaccination. She had
normal renal function and laboratory parameters prior to vaccination,
and this raises the suspicion of potential association between AAV and
COVID-19 vaccine.
Genetic factors, infectious agents, some drugs, and environmental
factors are thought to initiate the pathogenesis of AAV. There are
studies suggesting the potential association between various infections
and the occurrence of vasculitis (8). However, whether the infections or
vaccinations are the triggering factors for autoimmune conditions like
vasculitides still lacks direct evidence. A study pointed out the
increased level of ANCA in patients immunized with RNA based influenza
and rabies vaccine (9,10). Furthermore, there have been reports of AAV
and other autoimmune conditions due to SARS-CoV-2 infections and
vaccinations (mRNA COVID-19 vaccines) (11,12). Interestingly, our
patient developed AAV following adenovirus vector vaccine in contrast to
the reports of AAV and glomerulonephritis following m-RNA COVID-19
vaccines (1,2). The temporal causal association between autoimmune
manifestations like AAV and COVID-19 vaccines can be explained by
hypothesized mechanisms like molecular mimicry, defective neutrophilic
apoptosis, polyclonal activation, and systemic proinflammatory cytokine
response. These mechanisms are likely to trigger autoimmune responses in
genetically susceptible individuals. Still there are many research going
on to fill the research gap on the development of ANCA associated with
COVID-19 vaccines.
There are only few case reports of AAV and ANCA glomerulonephritis
developing after mRNA COVID-19 vaccination (Pfizer-BioNTech and Moderna)
in the literature (1,2). AAV following adenovirus vector vaccine has not
been reported previously. We believe that this is the first case report
of AAV that occurred following adenovirus vector COVID-19 vaccine
administration. Our patient had been immunized with Johnson and Johnson
COVID-19 vaccine and developed AAV 10 days after the immunization. There
have been reports of AAV after administration of influenza vaccine
(10,13). So, as a lesson learnt from the past, we can speculate the
neutrophilic immune response to adenovirus vector present in Johnson and
Johnson vaccines, to be a potential trigger for development of AAV.
Derangement in the function and expression of MPO and PR3 present in
neutrophil granules have been known to cause pauci-immune vasculitis.
Although this case does not conclusively clarify the causal relationship
between adenovirus vector COVID-19 vaccine and AAV, further study in the
future will insight the association.