52-year-old man • intermittent fevers • recently received second dose of COVID-19 vaccine • tremors in all 4 extremities • Dx?

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doi:doi: 10.12788/jfp.0669

Case Reports

52-year-old man • intermittent fevers • recently received second dose of COVID-19 vaccine • tremors in all 4 extremities • Dx?

J Fam Pract. 2023 October;72(8):345-347 | doi: 10.12788/jfp.0669

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References

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2. Vaccine Adverse Event Reporting System. Accessed February 9, 2022. vaers.hhs.gov

3. Duarte-García A, Pham MM, Crowson CS, et al. The epidemiology of antiphospholipid syndrome: a population-based Study. Arthritis Rheumatol. 2019;71:1545-1552. doi: 10.1002/art.40901

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5. O’Leary RE, Hsiao JL, Worswick SD. Antiphospholipid syndrome in a patient with rheumatoid arthritis. Cutis. 2017;99:E21-E24.

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7. Nakayama T, Akahoshi M, Irino K, et al. Transient antiphospholipid syndrome associated with primary cytomegalovirus infection: a case report and literature review. Case Rep Rheumatol. 2014;2014:27154. doi: 10.1155/2014/271548

8. Cruz-Tapias P, Blank M, Anaya J-M, et al. Infections and vaccines in the etiology of antiphospholipid syndrome. Curr Opin Rheumatol. 2012;24:389-393. doi: 10.1097/BOR.0b013e32835448b8

9. Schultz NH, Sørvoll IH, Michelsen AE, et al. Thrombosis and thrombocytopenia after ChAdOx1 nCoV-19 vaccination. N Engl J Med. 2021;384:2124-2130. doi: 10.1056/nejmoa2104882

10. Cimolai N. Untangling the intricacies of infection, thrombosis, vaccination, and antiphospholipid antibodies for COVID-19. SN Compr Clin Med. 2021;3:2093-2108. doi: 10.1007/s42399-021-00992-3

11. Jinno S, Naka I, Nakazawa T. Catastrophic antiphospholipid syndrome complicated with essential thrombocythaemia after COVID-19 vaccination: in search of the underlying mechanism. Rheumatol Adv Pract. 2021;5:rkab096. doi: 10.1093/rap/rkab096

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13. Gringeri M, Battini V, Cammarata G, et al. Herpes zoster and simplex reactivation following COVID-19 vaccination: new insights from a vaccine adverse event reporting system (VAERS) database analysis. Expert Rev Vaccines. 2022;21:675-684. doi: 10.1080/14760584.2022.2044799

14. Cirillo N, Doan R. The association between COVID-19 vaccination and Bell’s palsy. Lancet Infect Dis. 2022;22:5-6. doi: 10.1016/s1473-3099(21)00467-9

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The development of antiphospholipid antibodies has been independently associated with rheumatoid arthritis,⁵ COVID-19,⁶ and CMV infection,⁷ as well as with vaccination for influenza and tetanus.⁸ There also are reports of antiphospholipid antibodies occurring in patients who have received adenovirus-vectored and mRNA COVID-19 vaccines.^9-11

Movement disorders occurring with APS are unusual, with approximately 1.3% to 4.5% of patients with APS demonstrating this manifestation.¹² One of multiple autoimmune-related movement disorders, APS-related movement disorder is most commonly associated with systemic lupus erythematosus (SLE), although it can occur outside an SLE diagnosis.⁴

Limited evidence suggests that COVID-19 vaccination can cause reactivation of dormant herpesviruses.

While APS-related movement disorder occurs with the presence of antiphospholipid antibodies, the pathogenesis of the movement disorder is unclear.⁴ Patients are typically young women, and the associated movements are choreiform. The condition often occurs with coagulopathy and arterial thrombosis.⁴ Psychiatric manifestations also can occur, including changes in behavior—up to and including psychosis.⁴

Evidence of COVID-19 vaccination reactivating herpesviruses exists, although it is rare and usually does not cause serious health outcomes.¹³ The annual incidence of reactivation related to vaccination is estimated to be 0.7 per 100,000 for varicella zoster virus and 0.03 per 100,000 for herpes simplex virus.¹³ The literature also suggests that the occurrence of Bell palsy—the onset of which may be related to the reactivation of a latent virus—may increase in relation to particular COVID-19 vaccines.^14,15 Although there is no confirmed explanation for these reactivation events at this time, different theories related to altering the focus of immune cells from latent disease to the newly generated antigen have been suggested.¹⁶

To date, reactivation has not been demonstrated with CMV specifically. However, based on the literature reviewed here on the reactivation of herpesviruses and the temporal relationship to infection in our patient, we propose that the BNT162b2 mRNA vaccination reactivated his CMV infection and led to his APS-related movement disorder.

Continue to: Treatment is focused on resolved the autoimmune condition