There are emerging cases of immune-mediated diseases post COVID-19 vaccination. 1 We report a case of adultonset Still disease (AOSD) after adenoviral vector vaccination (AstraZeneca). There has been one other case in the literature of documented AOSD post-adenoviral vector vaccination; the present case lends weight to a possible rare association.Mr NS, a 53-year-old marathon runner with no significant past medical history, presented to his general practitioner with a 1-week history of fatigue post initial vaccination with ChAdOx1 nCoV-19/AZD1222 (AstraZeneca). Workup at that stage was unremarkable. Ten weeks following his vaccination, he was urgently referred to the Emergency Department on 22 July 2021 with headache, arthralgia, malaise and fatigue. He was also noted to be thrombocytopenic with a platelet count of 88 Â 10 9 /L (reference range 150-400) associated with a raised D-dimer of 2.36 μg/mL FEU (reference range 0.00-0.40), and there was concern regarding the risk of thrombosis with thrombocytopenia.He complained of a 2-week history of worsening headaches, arthralgia, pharyngitis, rash and drenching sweats. Examination revealed, quotidian fevers of >39 C and a salmon-coloured rash over the anterior chest, back and limbs (Fig. 1). Mr NS was extremely stiff with pain on movement of the knees, in particular the left side, and no joint effusion was noted. Mild weakness was noted at the hip and shoulder girdles with difficulty sustaining muscle resistance. No lymphadenopathy was noted.Investigations carried out in the community 2 days prior to admission revealed: C-reactive protein (CRP) 56 mg/L (reference range <5), ferritin 3140 μg/L (reference range 30-300), erythrocyte sedimentation rate (ESR) 17 mm (reference range 1-15), aspartate aminotransferase 68 U/L (reference range 10-40) and alanine transaminase 62 U/L (reference range 5-40). During admission, levels of ferritin, CRP and ESR peaked at 10200 μg/L, 237 mg/L and 85 mm/h, respectively. In the setting of thrombocytopenia with raised D-dimer, a computed tomography pulmonary angiogram scan was performed that ruled out pulmonary embolism; no pulmonary infiltrate was noted. Abdominal ultrasound confirmed mild splenomegaly without lymphadenopathy.

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