Relapsed ANCA associated vasculitis following Oxford AstraZeneca ChAdOx1-S COVID-19 vaccination: A case series of two patients.

The coronavirus disease 2019 (COVID‐19) pandemic has precipitated the largest vaccination initiative in history. With a programme of this scale comes increasing descriptions of rare glomerular conditions developing post vaccination. We report two patients with relapsed microscopic polyangiitis (MPA) ANCA associated vasculitis (AAV) who received the Oxford AstraZeneca ChAdOx1‐S vaccine (AZV) within 5 weeks of developing symptoms (see Table 1). Whilst case reports of de novo vasculitis following COVID‐19 vaccination have been described, to our knowledge relapse of AAV in patients with a known history has not, raising questions regarding the safety of COVID‐19 vaccination use in this population.

TABLE 1

Clinical information and pathology results

Case	1	2	Reference range
Initial diagnosis date	2015	2019
Previous antibody	MPO Ab 1.2	MPO Ab 7	MPO Ab 0.0–3.4 U/ml
Prior therapy	Cyclophosphamide, rituximab, azathioprine, steroids	Steroids
Vaccination dates	08/06/2021	02/06/2021 11/08/2021
Symptom onset	14/07/2021	16/06/2021
Baseline creatinine and date	226 31/05/2021	75 12/05/2021	60–110 umol/L
Creatinine at presentation and date	227 17/07/2021	155 16/06/2021	60–110 umol/L
Peak creatinine and date	617 04/08/2021	882 16/08/2021	60–110 umol/L
ANCA	p‐ANCA @40	p‐ANCA >40
Antibody	MPO Ab 3.5	MPO Ab >134	MPO Ab 0.0–3.4 U/ml
Kidney replacement therapy	Yes	No
Pulmonary haemorrhage	Yes	No
Treatment	Pulse steroids, rituximab	Pulse steroids, cyclophosphamide
Creatinine at follow up	Dialysis dependent	307	60–110 umol/L

A 75‐year‐old man with historical renal‐limited MPA, previously in remission, presented with 3 days of haemoptysis, onset 5 weeks following the first dose of AZV. Serum creatinine was consistent with baseline; however, microscopic haematuria was newly present. P‐ANCA was positive, with anti‐MPO antibodies, having been negative at previous review. Kidney biopsy demonstrated active, pauci‐immune crescentic glomerulonephritis, consistent with AAV relapse. Methylprednisolone and rituximab were commenced and haemoptysis resolved, however kidney function deteriorated, requiring ongoing kidney replacement therapy.

A 74‐year‐old man with MPA, diagnosed 18 months previously with no prior kidney involvement, was referred with worsening kidney impairment, first noted 2 weeks following first AZV. He had received the second AZV on the morning of admission, the first dose given 10 weeks prior. Positive p‐ANCA with anti‐MPO >134 U/ml was noted. Kidney biopsy demonstrated acute crescentic pauci‐immune glomerulonephritis, consistent with AAV. Serum creatinine peaked at 882 umol/L, and dialysis access was organized. Intravenous methylprednisolone and cyclophosphamide were commenced, kidney function improved, and he was discharged without requiring kidney replacement therapy.

Whilst single cases of de novo AAV have been described following each of the AZV, Moderna and Pfizer COVID‐19 vaccinations,2, 3, 4, 5 this is the first report of AAV relapse following COVID‐19 vaccination. Our findings raise questions regarding COVID‐19 vaccination safety in those with known vasculitis. The scarcity of cases contrasted with the number of vaccines given is reassuring and should not change our practice in recommending vaccination to our patients; however, it would be prudent to monitor those with a history of vasculitis closely. Regarding the cases described here, recommending an alternative vaccination for future doses may be a sensible path forward.