New-Onset Psoriatic Arthritis Following COVID-19 mRNA Vaccination in a Psoriatic Patient Under Anti-tumor Necrosis Factor Alpha Biologic Treatment: What Now?

Abstract

During the COVID-19 pandemic, anti-SARS-CoV-2 vaccines were quickly developed and administered to the population worldwide. As is expected with new vaccine products, adverse reactions following immunization have been reported, namely, the development and/or exacerbation of autoimmune/autoinflammatory diseases, including rheumatic diseases. Here, we report a clinical case of a 56-year-old woman with a 44-year history of moderate-to-severe plaque psoriasis under treatment with an anti-tumor necrosis factor alpha biosimilar (adalimumab) with good control of skin disease and without rheumatic involvement to date who came to us with complaints of migratory polyarthralgia starting one week after receiving the second dose of the BNT162b2 COVID-19 mRNA vaccine. The condition progressed over the following months and a diagnosis of psoriatic arthritis was established. Biologic treatment was switched to an anti-interleukin 17A (secukinumab), with a very good clinical cutaneous and articular response, which was sustained up to the present moment. The mechanisms behind the exacerbation or new-onset of autoimmune/autoinflammatory diseases after receiving anti-COVID-19 vaccines are not yet fully understood, requiring further investigation. It is also not known whether rheumatic symptoms post-COVID-19 infection will have similar mechanisms to rheumatic symptoms post-anti-COVID-19 vaccination. With the continuing worldwide vaccination against SARS-CoV-2, clinicians need to be prepared to discuss the risks and benefits of vaccination and should be aware that it may cause or exacerbate immune disorders such as psoriatic arthritis, warranting close follow-up in terms of disease progression and treatment.

Keywords: autoimmune disease flare; biologic treatment; covid-19 vaccination; mrna vaccine; psoriasis; psoriatic arthritis; reactive arthritis.

Figure 1. Initial migratory polyarthritis.

Inflammatory signs of initial migratory polyarthralgia (August 2021): the first joint affected was the right knee (A), migrating to the left wrist (with forearm flexor tenosynovitis) (B, C, and D) and subsequently to the right wrist (E, black arrowheads showing soft tissue swelling) and right tibiotarsal joint (F, black arrowheads showing soft tissue swelling).

Figure 2. Osteoarthritis of the hands.

X-ray of the hands (A: frontal view; B: oblique view): radiological evidence of bilateral incipient osteoarthritis of the proximal interphalangeal joint of the fifth finger (yellow arrowheads showing diminished intra-articular space).

Figure 3. Therapeutic response to secukinumab.

Skin and joint therapeutic response to secukinumab 300 mg, subcutaneously, monthly (anti-IL17-A, Cosentyx®) just two months after starting therapy in June 2021. There is nearly complete remission of the psoriatic skin lesions (the extension of lesions corresponded to what we can now see as healed hypopigmented skin) and inflammatory signs at the joint level are absent (A, B, and C).