Reactions 1871, p205 - 4 Sep 2021

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Reactions 1871, p205 - 4 Sep 2021

Ibuprofen/prednisone/tozinameran

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Rheumatoid arthritis flare and lack of efficacy: case report

A 55-year-old man developed rheumatoid arthritis flare following vaccination with tozinameran for prevention of COVID-19.

Additionally, he exhibited lack of effectiveness during treatment with ibuprofen and prednisone for rheumatoid arthritis for rheumatoid arthritis flare [routes not stated; not all dosages stated].

The man, who had non-erosive, seropositive rheumatoid arthritis in sustained clinical remission for more than two years, had developed an acute flare 12 hours following the second dose of tozinameran [BNT162b2] vaccination manufactured by BioNTech- Pfizer for prevention of COVID-19. He had been in remission on upadacitinib therapy since July 2018. At the last clinic visit in September 2020, he had been still in remission. He had tested negative for SARS-CoV-2 by PCR in April 2020, when he was screened for work. He received the first vaccine dose on 23 December 2020, after which he reported of minor arthralgias which resolved within one day. The second vaccine dose was administered on 13 January 2012 at the age of 55 years. Within 12 hours following the second dose, he developed significant pain and swelling in his right knee suggestive of rheumatoid arthritis flare up.

The man received treatment with ibuprofen and prednisone 5mg daily immediately after the pain and swelling, but his symptoms persisted. He was advised to increase the dose of prednisone to 10mg daily. Despite the increased dose, his symptoms persisted.

He presented to clinic on 22 January 2021, and an ultrasound was performed. He had continued the usual upadacitinib therapy between the two vaccinations. He had significant swelling and warmth over his right knee with pain. Ultrasound of the right knee revealed a moderate to large compressible hypoechoic effusion in his suprapatellar recess which extended from the suprapatellar bursa to the quadriceps tendon involving the medial and lateral gutter. He showed increased power Doppler signal in the effusion of the lateral gutter. Additionally, a popliteal cyst was noted with a large effusion in his posterior knee deep to the semimembranosus tendon. Arthrocentesis of the right knee revealed 24mL of inflammatory-appearing effusion. Synovial fluid studies and blood parameters were determined. His rheumatoid arthritis was well controlled prior to the vaccination, and it was believed that the flare might have been triggered by the immune response to a component of the vaccine. He received treatment with unspecified steroids, and rapid improvement was achieved with clinical remission.

Terracina KA, et al. Flare of rheumatoid arthritis after COVID-19 vaccination. The Lancet Rheumatology 3: e469-e470, No. 7, Jul 2021. Available from: URL: http://

doi.org/10.1016/S2665-9913%2821%2900108-9 803593293