Dermatomyositis Post COVID-19 Vaccine: A Case Report

Dermatomyositis (DM) is a rare systemic autoimmune disease characterized by symmetrical and predominantly proximal muscle weakness in the limbs, associated with typical skin lesions. Autoimmune diseases have already been described as an adverse effect of vaccines. Case-report: A 65-year-old Caucasian female patient evolved, 5 days after the first dose of the AZD1222 vaccine against the COVID-19 virus, with skin lesions suggesting heliotrope and Gottron’s sign, with partial improvement of the condition with use of topical glucocorticoids in the lesions. After two months, the patient received the second dose of AZD1222 vaccine, and evolved with proximal muscle weakness of upper and lower limbs, dysphagia, increase of muscle enzymes, in addition to skin lesions compatible with heliotrope and Gottron’s sign again. After treatment with pulse therapy with methylprednisolone 1000 mg per day for three days and treatment with immunosuppressants, she evolved with significant clinical improvement. Conclusions: This case-report demonstrating an important chronological relationship between dermatomyositis and the vaccine AZD1222 alerts to the possibility of the disease as an important adverse reaction of vaccine against COVID-19 virus, as has been recently described by other authors.

Open Journal of Rheumatology and Autoimmune Diseases males. The cause of DM is unknown, but it is believed to be multifactorial, involving the interaction of genetic and environmental factors [1]. Infections, immunodeficiencies and other external factors such as vaccines could act in genetically predisposed individuals, favoring changes in immunoregulatory mechanisms responsible for the manifestations of the disease.
The progressive growth of registered cases of COVID-19 in the world generated immense concern from the authorities and since the beginning of 2021 when the vaccination program started, side effects have been reported in clinical trials [2].
Among the adverse effects induced by the vaccines, some that have been reported include autoimmune diseases like myocarditis, vaccine-induced immune thrombotic thrombocytopenia and leukocytoclastic vasculitis [3].
In this report, we will describe a case report of a patient who developed dermatomyositis after receiving the ChAdOx1 nCoV-19 (AZD1222) vaccine.

Discussion
To date, this is one of the first case-reports to describe dermatomyositis after vaccination against COVID-19 virus.
In December 2019, the Chinese Center for Disease Control and Prevention reported several cases of pneumonia of unknown cause. The first complete identification of the genome of the new virus was completed in January 2020, initially being called 2019-nCoV and later being renamed to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), with the disease caused by the virus becoming known as coronavirus disease 2019 (COVID-19). The COVID-19 can generate asymptomatic conditions to serious illness and death [4].
Brazil is among the countries with the highest numbers of confirmed cases and deaths from SARS-CoV-2 since the beginning of the pandemics. Vaccination is essential to reduce morbidity and mortality in these patients [5].
Until recently, little was known about efficacy and safety in patients with rheumatologic diseases, as the vast majority of vaccine studies excluded patients with these comorbidities. A recently published article carried out at a tertiary center in Brazil demonstrated slightly lower post-vaccination seroconversion in patients with autoimmune diseases, but with satisfactory safety and no reports of serious side effects [6].
On the other hand, there is an increase in the number of case reports of au-Open Journal of Rheumatology and Autoimmune Diseases toimmune diseases discovered soon after vaccination, and questions are being asked about it, because so far, there is no way to prove if they were just coincidence or if they had a true temporal and causal relationship with the vaccine.
Some cases of post-vaccination dermatomyositis are being published recently [12] [13] [14] [15], which raise the suspicion that this relation is not just a coincidence. In these cases, the disease-associated vaccines were AZD1222 (Astra-Zeneca), mRNA 1273 (Moderna) and Biotech (Pfizer). As in the majority of reported cases, the patient of this case report was an elderly woman with good response after induction treatment, demonstrating a possible good prognostic of dermatomyositis induced COVID-19 vaccine. Unlike other reported cases, the patient of this case report developed skin lesions suggestive of heliotrope and Gottron's sign, typical lesions of dermatomyositis, in addition to joint involvement, with arthralgia.
Previously, some cases of DM were reported after vaccination against hepatitis B and Influenza [16] [17] [18]. Although, in the phase III study of AZD1222 vaccine there were no reports of post-vaccination autoimmune phenomena, this study demonstrated efficacy of 74.0% against COVID-19, with few serious adverse effects, the most common adverse events being auto-limited generalized pain, headache, pain at the injection site and fatigue [19].
Among the potential triggers, viruses have the potential to break down tolerance and trigger an immune inflammatory myopathy [20]. During the COVID-19 pandemic, there is evidence that more than 10% of patients infected with COVID-19 develop myopathic symptoms with myalgia, weakness, and elevated CK, but until recently there were no reports of COVID-19 infection or vaccines for COVID-19 as triggers for the onset of dermatomyositis [18]. The mechanisms of autoimmune phenomena after vaccination may be analogous to those that occur after natural infections, so the justification may be based on molecular mimicry, epitope dissemination and disorderly activation of the immune system [21].

Conclusion
The low incidence of DM makes the analysis between vaccines and the onset of the disease difficult, but based on the temporal relationship between onset of the clinical case described and the administration of the vaccine doses shows a very likely cause-and-effect association, although, unquestionable proof of causality in humans would require larger future epidemiological studies.