A 45-year-old woman with a new onset of systemic lupus erythematosus and chronic myelomonocytic leukemia after receiving the COVID-19 vaccination

Jayadi; Widya Inarah NH; Rahmawati Minhajat; Suriani Alimuddin; Andi Fachruddin Benyamin; Tutik Harjianti; Sahyuddin Saleh; Dimas Bayu

doi:10.22146/inajbcs.v57i3.Supplement.24553

Jayadi Hematology and Medical Oncology Division, Internal Medicine Department, Faculty of Medicine of Hasanuddin University, Makassar, Indonesia
Widya Inarah NH Hematology and Medical Oncology Division, Internal Medicine Department, Faculty of Medicine of Hasanuddin University, Makassar, Indonesia
Rahmawati Minhajat Hematology and Medical Oncology Division, Internal Medicine Department, Faculty of Medicine of Hasanuddin University, Makassar, Indonesia
Suriani Alimuddin Clinical Allergy and Immunology Division, Internal Medicine Department Faculty of Medicine of Hasanuddin University, Makassar, Indoneisa
Andi Fachruddin Benyamin Hematology and Medical Oncology Division, Internal Medicine Department, Faculty of Medicine of Hasanuddin University, Makassar, Indonesia
Tutik Harjianti Hematology and Medical Oncology Division, Internal Medicine Department, Faculty of Medicine of Hasanuddin University, Makassar, Indonesia
Sahyuddin Saleh Hematology and Medical Oncology Division, Internal Medicine Department, Faculty of Medicine of Hasanuddin University, Makassar, Indonesia
Dimas Bayu Hematology and Medical Oncology Division, Internal Medicine Department, Faculty of Medicine of Hasanuddin University, Makassar, Indonesia

DOI: https://doi.org/10.22146/inajbcs.v57i3.Supplement.24553

Keywords: Systemic lupus erythematosus, chronic myelomonocytic leukemia, systemic autoimmune and/or inflammatory disease, inactivated COVID-19 vaccination, case report

Abstract

Systemic lupus erythematosus (SLE) is an autoimmune disease that attacks organs and cells mediated by autoantibodies and immune complexes. Meanwhile, chronic myelomonocytic leukemia (CMML) is a myeloid stem cell disease characterized by monocytosis, often associated with other myeloproliferative disorders. Approximately 20% of CMML cases are associated with systemic autoimmune and/or inflammatory disease (SAID). We report a 45-year-old woman admitted to Wahidin Sudirohusodo Hospital in September 2021 with shortness of breath. Inactivated COVID-19 vaccination was on July 3 and August 26, 2021, and tested positive for COVID-19 a week after the first dose. Physical examination: pale conjunctiva, medio-basal rhonchi in both lungs, hepatomegaly, ascites with shifting dullness, petechiae, and ecchymosis on extremities. Laboratory findings: persistent leucocytosis and monocytosis, normocytic normochromic anaemia, thrombocytopenia, hypoalbuminemia, and proteinuria. Positive ANA profile for: anti-RNP/anti-SM/anti-SSA/anti-ribosomal protein/anti-Ro. Peripheral blood analysis: suspicion of CMML, BMP: CMML and BCR-ABL1 transcripts were not detected. Renal biopsy: focal nephritis grade III, and decreased glomerular filtration rate. CXR: bronchopneumonia. She was diagnosed with SLE, CMML, lupus nephritis, and pneumonia. Initial treatment with pulse dose methylprednisolone, ceftazidime, and supportive therapy. Various adjustments of oral therapy, including methylprednisolone, hydroxychloroquine, cyclosporine, mycophenolate acid, and vitamin D. While vaccination remains the most effective option in preventing COVID-19, it can be associated with medical complications. COVID-19 vaccines may alter gene expression in T lymphocytes, resulting in an overexpression of lymphocyte function and subsequent autoreactivity. Adjuvants can trigger inflammation by stimulating the release of proinflammatory cytokines, including interferon, IL-1, and IL-6. The pathophysiological links between CMML and the COVID-19 vaccine are not fully understood. However, several hypotheses have been proposed to explain the association between CMML and SAID. The primary goal of therapy is to achieve remission without inducing cytopenias or other hematologic abnormalities. SLE activity and hematologic profiles in this patient improved during therapy.