J Korean Med Sci.  2022 Mar;37(11):e91. 10.3346/jkms.2022.37.e91.

Clinicopathological Characteristics of Inflammatory Myositis Induced by COVID-19 Vaccine (Pfizer-BioNTech BNT162b2): A Case Report

• Kim JH
• Kim JH
• Woo CG

• KMID: 2527451
• DOI: http://doi.org/10.3346/jkms.2022.37.e91

Abstract

As more individuals were coronavirus disease 2019 (COVID-19) vaccinated, unexpected side effects appeared. Herein, we present the case of a 30-year-old male patient with myopathy in both extremities after the second dose of the Pfizer-BioNTech (BNT162b2) COVID-19 vaccine. Symptoms, swelling and pain, started from the proximal upper and lower extremities and extended to the distal parts. Although he underwent massive hydration, the muscle enzyme level continuously increased. He complained of dysphagia and dysarthria. Microscopically, muscle biopsy showed multifocal or scattered macrophage infiltration and degenerated myofibers. In contrast to general myopathy including inflammatory myositis and rhabdomyolysis, vaccine-induced inflammatory myositis shows a prolonged increase in muscle enzyme levels and multifocal macrophage infiltration with necrosis of the muscle fibers. Symptoms improved with glucocorticoid and immunosuppressive treatment. If vaccinated individuals experience severe and continuous muscle pain and swelling, clinicians should consider vaccine-induced inflammatory myositis, measure the muscle enzyme levels, and perform muscle biopsy for a definite diagnosis.

Keyword

Coronavirus; Vaccination; Myopathy; Rhabdomyolysis; Inflammatory Myositis

Figure

• 

  Fig. 1 Erythematous purpuric plaques on the trunk (A) and both hands (B).

• 

  Fig. 2 Diffuse muscular enhancement on the adductor, quadriceps femoris, and hamstring muscles of both thighs (A) and the entire head and neck muscles (B) on enhanced magnetic resonance imaging.

• 

  Fig. 3 Histopathology of muscle biopsy in the thigh. Multifocal infiltrates (arrows) of large polygonal-shaped macrophages having amphophilic cytoplasm in the endomysium, intermingled with a few lymphocytes on hematoxylin and eosin staining (A). Multifocal and scattered macrophages infiltration in the perimysium, epimysium, and endomysium, confirmed by immunohistochemistry for CD68 (B). The degenerated or necrotic muscle fibers (arrows) demonstrated with Masson’s trichrome staining (C).

Reference

1. Wang L, Xiang Y. Spike glycoprotein-mediated entry of SARS coronaviruses. Viruses. 2020; 12(11):1289.

2. Polack FP, Thomas SJ, Kitchin N, Absalon J, Gurtman A, Lockhart S, et al. Safety and efficacy of the BNT162b2 mRNA Covid-19 vaccine. N Engl J Med. 2020; 383(27):2603–2615. PMID: 33301246.

3. Oliver SE, Gargano JW, Marin M, Wallace M, Curran KG, Chamberland M, et al. The advisory committee on immunization practices’ interim recommendation for use of Pfizer-BioNTech COVID-19 vaccine - United States, December 2020. MMWR Morb Mortal Wkly Rep. 2020; 69(50):1922–1924. PMID: 33332292.

4. Remmel A. Why is it so hard to investigate the rare side effects of COVID vaccines? Nature. Forthcoming. 2021; DOI: 10.1038/d41586-021-00880-9.

5. Gherardi RK, Authier FJ. Macrophagic myofasciitis: characterization and pathophysiology. Lupus. 2012; 21(2):184–189. PMID: 22235051.

6. Israeli E, Agmon-Levin N, Blank M, Shoenfeld Y. Macrophagic myofaciitis a vaccine (alum) autoimmune-related disease. Clin Rev Allergy Immunol. 2011; 41(2):163–168. PMID: 20882368.

7. Kim H, Lim KY, Kang J, Park JW, Park SH. Macrophagic myofasciitis and subcutaneous pseudolymphoma caused by aluminium adjuvants. Sci Rep. 2020; 10(1):11834. PMID: 32678281.

8. Schmidt J. Current classification and management of inflammatory myopathies. J Neuromuscul Dis. 2018; 5(2):109–129. PMID: 29865091.

9. Khosla SG, Nylen ES, Khosla R. Rhabdomyolysis in patients hospitalized with COVID-19 infection: five case series. J Investig Med High Impact Case Rep. 2020; 8:2324709620984603.

10. Rivas-García S, Bernal J, Bachiller-Corral J. Rhabdomyolysis as the main manifestation of coronavirus disease 2019. Rheumatology (Oxford). 2020; 59(8):2174–2176. PMID: 32584414.

11. Aschman T, Schneider J, Greuel S, Meinhardt J, Streit S, Goebel HH, et al. Association between SARS-CoV-2 infection and immune-mediated myopathy in patients who have died. JAMA Neurol. 2021; 78(8):948–960. PMID: 34115106.

12. Alrubaye R, Choudhury H. Severe rhabdomyolysis in a 35-year-old woman with COVID-19 due to SARS-CoV-2 infection: a case report. Am J Case Rep. 2020; 21:e926733. PMID: 32801291.

13. Walsh EE, Frenck RW Jr, Falsey AR, Kitchin N, Absalon J, Gurtman A, et al. Safety and immunogenicity of two RNA-based Covid-19 vaccine candidates. N Engl J Med. 2020; 383(25):2439–2450. PMID: 33053279.

14. Roncati L, Nasillo V, Lusenti B, Riva G. Signals of T_h2 immune response from COVID-19 patients requiring intensive care. Ann Hematol. 2020; 99(6):1419–1420. PMID: 32382776.

15. Kaulen LD, Doubrovinskaia S, Mooshage C, Jordan B, Purrucker J, Haubner C, et al. Neurological autoimmune diseases following vaccinations against SARS-CoV-2: a case series. Eur J Neurol. 2022; 29(2):555–563. PMID: 34668274.

16. Nassar M, Chung H, Dhayaparan Y, Nyein A, Acevedo BJ, Chicos C, et al. COVID-19 vaccine induced rhabdomyolysis: case report with literature review. Diabetes Metab Syndr. 2021; 15(4):102170. PMID: 34186348.

17. Maramattom BV, Philips G, Thomas J, Santhamma SG. Inflammatory myositis after ChAdOx1 vaccination. Lancet Rheumatol. 2021; 3(11):e747–e749. PMID: 34585145.

18. Ramalingam S, Arora H, Lewis S, Gunasekaran K, Muruganandam M, Nagaraju S, et al. COVID-19 vaccine-induced cellulitis and myositis. Cleve Clin J Med. 2021; 88(12):648–650. PMID: 34857596.

19. Kim D, Choi JH, Jang JY, So O, Cho E, Choi H, et al. A case report for myopericarditis after BNT162b2 COVID-19 mRNA vaccination in a Korean young male. J Korean Med Sci. 2021; 36(39):e277. PMID: 34636504.

20. Choi S, Lee S, Seo JW, Kim MJ, Jeon YH, Park JH, et al. Myocarditis-induced sudden death after BNT162b2 mRNA COVID-19 vaccination in Korea: case report focusing on histopathological findings. J Korean Med Sci. 2021; 36(40):e286. PMID: 34664804.

21. Kim G, Choi EJ, Park HS, Lee JH, Lee JH, Lee KH. A case report of immune thrombocytopenia after ChAdOx1 nCoV-19 vaccination. J Korean Med Sci. 2021; 36(43):e306. PMID: 34751013.

22. Park JW, Yu SN, Chang SH, Ahn YH, Jeon MH. Multisystem inflammatory syndrome in an adult after COVID-19 vaccination: a case report and literature review. J Korean Med Sci. 2021; 36(45):e312. PMID: 34811978.