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Gene & Protein in Disease MIS-A with LETM after SARS-CoV-2 vaccine

vaccines widely used in India. Nonreplicating adenovirus noncontributary. Physical examination revealed that the
is used in COVISHIELD to express SARS-CoV-2 spike patient had pulse rate of 130/min, blood pressure of 120/86
™
protein, which is presented to the antigen-presenting cells mmHg on injection noradrenaline infusion, and breathing
of the host . Various hypotheses have been proposed to rate of 26 breaths/min. With the aid of an oxygen face mask
[4]
delineate the exact mechanisms causing immune-mediated administering oxygen at 8 L/min, her oxygen saturation was
neurological complications following SARS-CoV-2 maintained at 98%. Neurologically, Glasgow–Coma scale
vaccination, and among them, molecular mimicry is (GCS) was 15/15. Higher mental functions and cranial nerve
recognized as the most plausible mechanism . Components findings of the patient were normal. An examination of her
[5]
of the adenovector-based SARS-CoV-2 vaccine can activate motor system revealed that she had flaccid quadriparesis
an unregulated inflammatory cascade, which damages with medical research council (MRC) grade 4+/5 power in
the brain and peripheral nerves . In adenovector-based upper limbs and MRC grade 0/5 power in lower limbs. All
[5]
SARS-CoV-2 vaccines, the SARS-CoV-2 spike protein may reflexes were absent and plantars were mute. She had reduced
also act as an autoantigen, with the adjuvants enhancing sensation to touch, pain, and temperature below umbilicus,
the immune reactivity further . MIS-A after SARS-CoV-2 which was more pronounced in the lower back and lower
[5]
vaccination is an extremely rare complication [6-8] . limbs. Blood investigations revealed polymorphonuclear
According to the definition by Center for Disease Control leukocytosis, thrombocytopenia, acute kidney injury, acute
and Prevention (CDC), USA, MIS-A encompasses a liver injury, and disseminated intravascular coagulation.
spectrum of new-onset neurological manifestations, Reverse-transcription polymerase chain reaction (RT-PCR)
such as encephalopathy, seizures, signs of meningeal test for SARS-CoV-2 was negative. Table 1 presents the
irritation, and peripheral neuropathy like Guillain–Barre results of preliminary investigations.
syndrome; the presence of these manifestations constitutes
the secondary clinical criteria of MIS-A. Longitudinally Chest X-ray showed features of acute respiratory
extensive transverse myelitis (LETM) is regarded as a rare distress syndrome. 2D echocardiography showed global
complication after SARS-CoV-2 vaccination [8,9] . Thus far, left ventricular hypokinesia with left ventricular ejection
only one case has been described, establishing LETM as fraction (LVEF) of 40 – 45%. The level of N-terminal
a neurological complication of MIS-C after SARS-CoV-2 pro B type natriuretic peptide (NT Pro-BNP) was found
infection . Here, we report a case of MIS-A with LETM to exceed 70000 pg/mL. Within 1 day of admission,
[10]
after SARS-CoV-2 vaccination in an adult woman. she became febrile but testing of viral markers and
tropical fever showed negative results. The patient also
2. Case presentation had a normal vasculitis profile and serum angiotensin-
converting enzyme (ACE) level, but the levels of serum
A 38-year-old female was presented at our hospital with inflammatory markers, such as C-reactive protein (CRP),
acute-onset progressive flaccid quadriparesis on December interleukin-6 (IL-6) and procalcitonin, were raised. Total
26, 2021, which had progressed for more than 36 h with SARS-CoV-2 antibody titer, measured by ELISA, was
sign of sensory paresthesia up to lower abdomen with 2816 IU/mL (normal <1000 IU/mL). On January 2, 2022,
bladder and bowel involvement, accompanied by urinary she developed maculopapular rash over the angle of mouth
retention and bowel incontinence. This patient has a and the face. In view of the presence of cardiac illness,
medical history of hypothyroidism in the last 5 – 6 years rashes, new-onset neurological signs and symptoms,
but has not been on regular medication. She also has a shock, thrombocytopenia, as well as raised CRP, IL-6,
history of mild SARS-CoV-2 infection in May 2021 from procalcitonin, and SARS-CoV-2 antibody levels, she was
which she recovered in 2 weeks, and received the second diagnosed as having MIS-A with underlying sepsis.
dose of SARS-CoV-2 vaccine (COVISHIELD , ChAdOx1
™
nCoV-19 Corona Virus Vaccine) on November 1, 2021. Accordingly, the patient was treated with mechanical
She had breathing difficulty since December 28, 2021, ventilation, ionotropic support in the form of noradrenaline
requiring ventilator support, and faced severe hypotension injection, intravenous immunoglobulin (IVIG) 2 g/kg
necessitating ionotropic support in the form of injection over 5 days since January 2, 2022, intravenous broad-
noradrenaline and vasopressin. There was no immediately spectrum antibiotics, and hemodialysis, along with other
preceding history of fever, headache, photosensitive supportive management. Contrast-enhanced computed
rashes, or recurrent orogenital ulcers. The patient showed tomography of chest and abdomen conducted on January
a history of low-grade fever in November after SARS- 6, 2022, revealed diffuse ground-glass opacity and
CoV-2 vaccination for which she took intermittent consolidation in the bilateral lung field involving perihilar,
non-steroidal anti-inflammatory medication. Dietary, peripheral, and bilateral upper lobes. An analysis of the
family, psychosocial, family, and obstetric history was patient’s cerebrospinal fluid revealed albumin-cytological

Volume 2 Issue 3 (2023) 2 https://doi.org/10.36922/gpd.1320