BackgroundHydroxychloroquine (HCQ) is an antimalarial drug that is recommended as a safe, daily prophylactic intervention for individuals with systemic lupus erythematosus (SLE) based on previous studies that showed an association of HCQ use with reductions in flares compared with placebo. Our study aims to determine whether the discontinuation of HCQ leads to relapse of disease and whether the duration of HCQ use impacts the success of its eventual discontinuation.MethodsA retrospective chart review was performed on the medical records of patients diagnosed with SLE between July 1, 2006, and June 30, 2016. The data gathered included demographic factors, diagnostic symptoms, laboratory values, and SLE medications. Additionally, HCQ usage and discontinuation rates were collected as well as the timing and prevalence of flares during and after HCQ usage. Patients who were diagnosed with SLE but never used HCQ were excluded from the study. The occurrence of flares, clinical characteristics, and duration of treatment with HCQ were compared between the group that continued HCQ and the group that discontinued HCQ.ResultsOf the 509 patients who met inclusion criteria, 66.2% (n = 337) continued HCQ throughout the duration of their treatment (median duration of HCQ treatment was 8.0 years), whereas 33.8% (n = 172) did not (median duration of HCQ treatment was 1.9 years). Patients who received HCQ for less than 1 year before discontinuation (median duration of HCQ treatment was 2.5 months) were more likely to experience SLE flares compared with those who continued HCQ for more than 1 year (13.1% vs 5.7%, P = 0.019). Patients who experienced a flare while on HCQ were more likely to have arthritis, oral ulcers, leukopenia, and thrombocytopenia.ConclusionWith over 500 patient charts reviewed, this is the largest study comparing outcomes for patients on HCQ with those who discontinued it. Patients who discontinue HCQ after being on it for less than 1 year are at greater risk for flares compared with those who take HCQ for longer than 1 year. These findings should be used to guide treatment, educate patients on the role of continued treatment with HCQ, and ultimately reduce morbidity and mortality.

Giant cell arteritis (GCA) is a large vessel vasculitis with variable presentations, including fevers, myalgias, headache, and jaw claudication. A particularly concerning symptom is transient vision loss, which may become irreversible without prompt recognition and treatment. The pathogenesis of GCA is incompletely understood, but it seems that the innate and adaptive immune systems play a key role in vessel inflammation, remodeling, and occlusion. We present a case of a 79-year-old male who developed GCA two days after he received his second dose of a COVID-19 mRNA vaccine. He presented with headaches, fever, and myalgias. Lab workup revealed elevated inflammatory markers, with C-reactive protein (CRP) 272 mg/L (<8.1 mg/L) and erythrocyte sedimentation rate (ESR) 97 mm/hr (0-20mm/hr). Imaging of the head, with CT and MRI, was unremarkable. His headache persisted despite supportive treatment, and he developed new, transient blurred vision, which increased suspicion for GCA. He underwent bilateral temporal artery biopsies, which were consistent with GCA. His symptoms resolved quickly with oral prednisone 60mg daily, and his inflammatory markers returned to normal within a month. A review of the literature revealed several case reports of giant cell arteritis following influenza vaccination. However, no large-scale studies have demonstrated a causal relationship between GCA and immunization. Our case demonstrates the first instance of GCA following a COVID-19 mRNA vaccine. We propose that the upregulated immune response to the vaccine acted as a trigger for GCA in this patient with predisposing factors. While causation cannot be determined based on one case alone, our case demonstrates an opportunity for further research into the relationship between vasculitis and immunizations. Despite this isolated case, the proven benefits of COVID-19 mRNA vaccines significantly outweigh any theoretical risk of immune dysregulation following administration.

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