Orbital myositis and scleritis after anti-SARS-CoV-2 mRNA vaccines: A report of three cases

Abstract

Purpose To report three cases of ocular myositis and scleritis, bilateral scleritis and unilateral single muscle myositis after mRNA COVID-19 vaccination. Methods Case series of three patients who presented to the Orbit Outpatient Service of Fondazione Policlinico Universitario A. Gemelli with a history of unilateral proptosis, diplopia and pain, bilateral red eye and pain during eye movements and unilateral proptosis and inconstant diplopia respectively with onset 5–10 days after m-RNA COVID-19 vaccine. A thorough hematologic work up and orbital contrast enhanced magnetic resonance imaging (MRI) in patients with proptosis was performed. Results Patients were females, 64, 58 and 45 years old respectively. MRI showed enlargement of all right rectus muscles, with both muscle belly and insertion involvement in the first case associated to right scleritis. A bilateral scleritis was diagnosed in the second patient and a single muscle myositis in the third patient. Serological tests excluded thyroid diseases. The first and second patient were treated respectively with oral and topical glucorticoids with a complete clinical response. Two 2 cycles of oral non-steroidal anti-inflammatory drugs were administered to the third patient with a partial response. Conclusion As far as we know these are the first report of orbital myositis and scleritis presenting after mRNA BNT162b2 vaccine (Pfizer/BioNTech) and mRNA-1273-(Moderna) vaccine, an uncommon effect of a likely autoimmune reaction triggered by the virus antigen.

Don’t promise something that is not there

“…We read with interest the article by Savino et al about three patients with alleged orbital myositis following vaccination with an RNA-based anti-SARS-CoV-2 vaccine. 1 The previous history was positive for ANCA-positive vasculitis in patient-1 (64yo female), for Hashimoto thyroiditis in patient-2 (58yo female), and was uneventful for patient-3 (45yo female). 1 The study is appealing but raises concerns that should be discussed.…”

“…1 The previous history was positive for ANCA-positive vasculitis in patient-1 (64yo female), for Hashimoto thyroiditis in patient-2 (58yo female), and was uneventful for patient-3 (45yo female). 1 The study is appealing but raises concerns that should be discussed.…”

“…1 Even more disturbing is that patient-2 did not undergo MRI of the orbita at all, as there is neither a description of this investigation nor a figure that shows the pathology. 1 Furthermore, patient-3 had undergone MRI of the orbita with contrast medium showing enlargement of the extra-orbital muscles but no enhancement. 1 Diagnosing orbital myositis without documenting enhancement if the extra-ocular muscles is not allowed.…”

“…A further discrepancy refers to the statement that patient-1 had no systemic symptoms and the diagnosis ANCA-positive vasculitis. 1 The reader should be informed how ANCA-positive vasculitis manifested clinically and which treatment patient-1 received for this disease. Particularly, we should know if the patient was on a long-term treatment with any biological or TNF-receptor analogue.…”

“…A shortcoming of the study is that an infection with SARS-CoV-2 was not ruled out by PCR. 1 Orbital myositis has been repeatedly reported as manifestation of SARS-CoV-2 infection. 5…”