A case of psoriatic spondyloarthritis exacerbation triggered by COVID-19 messenger RNA vaccine.

Author contributions

All authors approved the final version of this manuscript. SO had full access to all the data. SH reviewed the skin findings. SO was responsible for the organization and coordination of the case.

Editor,

The coronavirus disease (COVID‐19) vaccines have been rapidly delivered to prevent the spread of the disease. In Japan, the mRNA vaccines ‘BNT162b2’ (Pfizer–Biotech) and ‘mRNA‐1273’ (Moderna) have been approved. Although the vaccines have effectively reduced the morbidity and severity of the disease, some patients developed autoimmune phenomena, such as thrombosis with thrombocytopenia and myocarditis. , Also, exacerbations occurred in psoriasis patients after their vaccination. , We report a case of psoriatic spondyloarthritis (SpA) exacerbation triggered by COVID‐19 mRNA vaccine.

The patient was a 30‐year‐old man with a history of plaque psoriasis, well‐controlled with topical treatment, for more than 10 years. He experienced lower back pain for several years, but he did not take any medications. Aside from that, the patient had no other subjective complaints. He had an unremarkable family history. Prior to vaccination, the patient reported no allergies, new medications or infectious symptoms. He received the second dose of the Moderna mRNA vaccine by the end of September 2021. One day following his second vaccination, the patient developed a low‐grade fever of 37.5°C. Also, the patient's psoriatic lesions, scattered throughout his entire body, worsened. This was associated with severe neck and hip pain, which appeared two days after the vaccination. He visited another hospital 40 days after the vaccination because of persistent fever with neck and hip pain. The blood tests showed a high C‐reactive protein (CRP) level, whilst the whole‐body computed tomography scan showed no specific lesions. His COVID‐19 antigen test was negative. He received loxoprofen, but it failed to alleviate his pain. Therefore, he was referred to our department 62 days after the vaccination.

On admission, he had normal vital signs. Physical examination revealed erythema with scaling throughout his entire body. Scalp and nail lesions were also observed (Fig. 1). His Psoriasis Area Severity Index, evaluated by a dermatologist, was 23.1. Joint swelling and tenderness were not noted, but he had enthesitis with a Spondyloarthritis Research Consortium of Canada Enthesitis Index of 8. The sacroiliac compression test was bilaterally positive. Blood testing revealed a CRP level of 4.90 mg/dL and an erythrocyte sedimentation rate level of 56 mm/h. Tests for bacterial and viral infection markers, antinuclear antibody, rheumatoid factor, anticyclic citrullinated peptide antibody and human leukocyte Antigen‐B27 were negative. Radiography of sacroiliac joint showed bilateral narrowing space. Cervical magnetic resonance imaging (MRI) showed enhancement effects on cervical interspinous ligament and sacroiliac MRI showed bilateral sacroiliitis (Fig. 2). Based on these findings, he was diagnosed with psoriatic SpA exacerbation, and he was treated with ixekizumab, to which he had a good clinical response.

Figure 1

Skin findings showed worsening psoriatic lesions. MRI, Magnetic resonance imaging.

Figure 2

Sacroiliac MRI showed bilateral sacroiliitis, and cervical MRI showed enhancement effects on cervical interspinous ligament.

To the best of our knowledge, this is the first report of psoriatic SpA exacerbation triggered by COVID‐19 mRNA vaccination. The mechanism behind psoriasis exacerbation after COVID‐19 vaccination is likely similar to that of other vaccines. Vaccination induces interleukin (IL)‐6, which stimulates T‐helper 17 cells to produce IL‐22, a significant contributor to keratinocyte proliferation in psoriasis. ,

In one report, all patients experienced psoriasis exacerbation within 14 days after their vaccination. Most exacerbations occurred after the second vaccination dose. , However, there were no significant differences regarding the exacerbation of psoriasis between the vaccine types. ,

Although a high safety profile against the COVID‐19 mRNA vaccine was observed in almost all psoriasis patients, and psoriasis patients should be recommended to receive COVID‐19 vaccine, , factors associated with psoriasis exacerbation after the COVID‐19 vaccination have not been clarified yet. Further prospective studies are warranted to investigate the exacerbation in patients with psoriasis after COVID‐19 mRNA vaccine. In conclusion, clinicians should be carefully aware of the occurrence of psoriasis exacerbation after COVID‐19 vaccination.

Conflicts of interest

All authors declare no conflicts of interest.

Funding sources

No specific funding was received from any bodies in the public, commercial or not‐for‐profit sectors to carry out the work described in this article.