Relentless bilateral occlusive vasculitis in a patient with Crohn’s disease treated with adalimumab after immunization with mRNA SARS-CoV-2 vaccine: a case report

Abstract

Abstract Background: To report a case of bilateral rapidly progressive visual loss in a patient with long-standing Crohn's disease treated with a TNF blocking agent for 4 months who received a second SARS-CoV-2 mRNA dose 7 weeks before onset. Case presentation: A 26-year-old female with a 5-year history of Crohn’s disease was treated with adalimumab (Humira®) bimonthly from March 2021 to the end of July 2021. She received a first dose of mRNA-1273 COVID-19 vaccine (Moderna®) on April 14th, 2021, and a second dose was given on May 18th, 2021. Forty-nine days after the second dose, she complained of a central scotoma in her right eye. Her ophthalmologist noticed bilateral subretinal fluid associated with mild vasculitis on angiography. She was treated with 50 mg/day of oral prednisone and then substituted two days later by acetazolamide 250 mg/day when she was referred to an uveitis specialist in the city. Visual acuity worsened, and she was hospitalized from July 29th to August 4th, 2021, for bilateral panuveitis with severe vasculitis. She received five days of 500 mg/day intravenous methylprednisolone, followed by oral prednisone 1.5 mg/kg/day plus 1200 mg/day intravenous acyclovir and 100 mg/day acetylsalicylic acid. Adalimumab was switched to infliximab (Inflectra®). When she was first seen at Jules-Gonin Eye Hospital on November 4, 2021, the visual acuity was reduced to light perception in both eyes (OU). Fundus examination revealed bilateral honeycomb macular atrophy and multiple peripheral focal lesions with massive retinal ischemia. Optic disc atrophy was present in the OU. Ocular infections were ruled out by an anterior chamber tap puncture and multiple serologies, including tropical infections. Antiphospholipid antibodies were repeatedly negative. There were no signs of systemic involvement, and Crohn's disease was inactive. For corticosteroid sparing, weekly injections of tocilizumab were performed for one year from 6th December 2021, and corticosteroids were progressively tapered to 7.5 mg/day in January 2023. Conclusions: This case study depicts a doomed visual fate in a young woman. Several hypotheses have been raised about the pathogenesis of the disease: either an autoimmune process with massive vascular occlusive disease, a reaction to biologic agent (adalimumab) injections or a boost of ocular inflammation after COVID-19 vaccination.