Rare side effects of COVID-19, vaccines top 2021’s most-read medical case studies

As countries continue to administer COVID-19 vaccines, including to children and those requiring a third dose, scientific research around the potential, rare side effects of the shots remains top of mind for many.

The medical understanding of SARS-CoV-2 and how to protect people against the disease has evolved greatly since scientists first identified the novel coronavirus in Wuhan, China, more than two years ago.

While the COVID-19 vaccines currently approved for use have gone through clinical trials and rigorous approval processes by governing health bodies, case reports of individual patients and their outcomes following COVID-19 infection or vaccination are a key part of early stage research.

Among the most popular sources for leading research is BMJ Case Reports, considered “the world’s largest repository of case reports.”

Not surprisingly, six of the journal’s top 10 most-read case reports in 2021 were related to adverse events following COVID-19 vaccination, and three were related to symptoms of infection. But the top case report is about a COVID-19 patient who made a miraculous recovery against all odds.

Here’s a roundup of the most-read case studies from the BMJ Case Reports, all of which are freely available as part of the journal’s pandemic policy.

118 DAYS ON A VENTILATOR

The most-read case report of 2021, published in March, describes a COVID-19 patient with multiple comorbidities who was successfully weaned off ventilation after 118 days, despite his recovery being complicated by recurrent septic episodes, as well as the need for advanced cardiovascular support and renal replacement therapy.

“To the best of our knowledge, this is the longest reported ventilated time and intensive care/hospital stay for a surviving patient with COVID-19 and highlights the importance of allowing sufficient time for clinical interventions to take effect, even when the prognosis appears bleak,” doctors wrote in the case report.

A 53-year-old Lebanese man was admitted to a U.K. hospital for COVID-19 pneumonia after dealing with a sore throat and cough for two weeks. His comorbidities included type 2 diabetes, hypertension, obstructive sleep apnoea and severe gastro-oesophageal reflux disease. By the third day of hospital admission, he had developed hypoxia — low oxygen in the tissues — and was intubated and transferred to the ICU for mechanical ventilation. He quickly developed acute kidney injury and cardiovascular collapse requiring inotropic support to change the force of the heart’s contractions. He also had a tracheotomy on day 23 of his ICU admission and began receiving ongoing renal replacement therapy on day 24. Over the next two months, doctors say he had multiple episodes of “significant respiratory deterioration” and pneumonia, which prolonged his need for ventilation.

Following a “combination of steroids, optimisation of antimicrobials and best supportive care,” the patient was eventually able to breathe without a ventilator come day 118 and was later discharged from the ICU on day 134. After spending another two months in rehabilitation (six months in total as an inpatient), he was sent home, however, doctors say he continues to experience breathlessness and requires mobility aids including a wheelchair and walker due to back pain.

MIS IN AN ADULT FOLLOWING VACCINATION

This case study, which was published in July, describes the first reported case of multisystem inflammatory syndrome (MIS) in an adult after COVID-19 vaccination. While COVID-19 vaccines are safe and affective, adverse events following vaccination can happen, including MIS, a rare but serious immune response that occurs when different parts of the body — including but not limited to the heart, lungs, and skin — become inflamed. While MIS has been reported more commonly in children and some adults following COVID-19 infection, experts stress that developing MIS following vaccination is very rare. According to the case study, there had been no other reports of either MIS-C or MIS-A following COVID-19 vaccination at the time of publication.

Doctors say a 44-year-old U.K. woman was admitted to the hospital after experiencing arm pain at the vaccine site a few days after receiving the Pfizer-BioNTech vaccine, which progressed to fever, diarrhea and abdominal pain over the following days. She also had a red rash on her chest and swollen muscles due to a buildup of fluid. According to the case report, the woman developed an “unprovoked” pulmonary embolism with acute kidney injury. After administration of an intravenous corticosteroid, the muscle swelling, skin rashes and acute kidney injury resolved. However, the patient needed a “prolonged in-hospital stay” for her rehabilitation.

HIVES AS THE INITIAL SYMPTOM OF INFECTION

The 54-year-old woman at the centre of this case study, published in March, presented at an emergency department with shortness of breath, a generalized weakness, and hives associated with an itching, burning sensation that progressively got worse over the three days prior. The woman did not have any other symptoms such as fever, chills, cough, nausea, diarrhea, abdominal pain, or sore throat. She had no known exposure to COVID-19, but tested positive for the disease upon arrival at the hospital.

The woman had a widespread rash on her arms and legs that was abnormally red, raised, and consistent with an urticarial rash. Treatment for the rash included oral antihistamines and a topical cream, given the intensity of her itchiness. An antiviral therapy was given via intravenous once a day for five days to help with her shortness of breath. Within 48 hours of initiation of this treatment, the woman’s rash had cleared and she was discharged on day five of hospitalization once she completed the antiviral therapy.

According to the case report, cutaneous manifestations, or skin rashes, as a symptom of COVID-19 infection are “mostly described as self-limiting.” While the report notes that urticarial rashes are not reported as the initial presentation symptom of COVID-19 infection, scientists say they can occur at the same time or after the onset of other, more common symptoms.

Here are the remaining most-read case reports from the BMJ Case Reports:

4. Guillain-Barre syndrome after COVID-19 vaccination

5. Sequential contralateral facial nerve palsies following COVID-19 vaccination first and second doses

6. Reactivation of herpes simplex keratitis following vaccination

7. Adult MIS in a patient who recovered from COVID-19 post vaccination

8. COVID-19 infection in the palatine tonsil tissue and detritus

9. Immune thrombocytopenic purpura and acute liver injury after COVID-19 vaccine

10. Reactive arthritis after COVID-19