Drug-induced sarcoidosis-like reaction three months after BNT162b2 mRNA COVID-19 vaccination: A case report and review of literature

Abstract

Background: A 70-year-old man with hepatitis C virus-related recurrent hepatocellular carcinoma was admitted for further diagnosis of a 1 cm iso-hyperechoic nodule in segment (S) 5.

Case summary: Gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging (EOB-MRI) revealed the nodule in S5 with a defect at the hepatobiliary phase, hyperintensity on diffusion weighted imaging (DWI) and hypointensity on apparent diffusion coefficient (ADC) map. Contrast-enhanced computed tomography revealed hypervascularity at the early phase, and delayed contrast-enhancement was observed at the late phase. Contrast-enhanced ultrasound (US) revealed incomplete defect at the late vascular phase. Inflammatory liver tumor, lymphoproliferative disease, intrahepatic cholangiocarcinoma (small duct type) and bile duct adenoma were suspected through the imaging studies. US guided biopsy, however, showed a noncaseating hepatic sarcoid-like epithelioid granuloma (HSEG), and histopathological analysis disclosed spindle shaped epithelioid cells harboring Langhans-type multinucleated giant cells. One month after admission, EOB-MRI signaled the disappearance of the defect at the hepatobiliary phase, of hyperintensity on DWI, of hypointensity on ADC map, and no stain at the early phase.

Conclusion: That the patient had received BNT162b2 messenger RNA (mRNA) coronavirus disease 2019 vaccination 3 mo before the occurrence of HSEG, and that its disappearance was confirmed 4 mo after mRNA vaccination suggested that the drug-induced sarcoidosis-like reaction (DISR) might be induced by the mRNA vaccination. Fortunately, rechallenge of drug-induced DISR with the third mRNA vaccination was not confirmed.

Keywords: BNT162b2 mRNA COVID-19 vaccine; Case report; Drug-induced sarcoidosis-like reaction; Ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging; Noncaseating granuloma; Th1/Th2 profile.

Figure 1

Clinical course of the patient. HCC: Hepatocellular carcinoma; HSLR: Hepatic sarcoidosis-like reaction.

Figure 2

Image findings. A: Gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging (EOB-MRI) finding, 1 cm defect in S5 at the hepatobiliary phase (white arrow); B: EOB-MRI finding, 1 cm hyperintensity in S5 on diffusion weighted imaging (white arrow); C: EOB-MRI finding, 1 cm hypointensity in S5 on apparent diffusion coefficient map (white arrow); D: Computed tomography (CT) finding, no nodule in S5; E: Contrast-enhanced CT (CECT) finding, 1 cm hypervascular nodule in S5 at the early phase; F: CECT finding, 1 cm delayed contrast enhancement at the late phase; G: Plain ultrasound (US) finding, 1 cm iso-hyperechoic nodule in S5 (reference with EOB-MRI), hepatobiliary phase (white arrow); H: Contrast-enhanced US finding, Incomplete defect in S5 at the late vascular phase (reference with EOB-MRI), hepatobiliary phase (white arrow); I: MRI finding, disappearance of the defect in S5 at the hepatobiliary phase.

Figure 3

Histopathological findings. A: Hematoxylin and eosin (HE) staining, low magnification Noncaseating hepatic sarcoid-like epithelioid granuloma with spindle shaped epithelioid cells (encompassed by yellow line) harboring Langhans-type multinucleated giant cells (circled black) (HE × 40); B: HE staining, high magnification of A (HE × 100).