Digala, Lakshmi

Govindarjan, Raghav

English

Shingrix is a non-live recombinant vaccine approved to prevent herpes zoster infection, and its efficacy, and safety are well studied. The risk of vaccine-related complications in myasthenia symptoms is higher with live vaccines. How­ever, Shingrix, a non-live vaccine causing exacerbation of the myasthenia symptoms, has not been reported to date. Herein, we present a case of stable myasthenia gravis that got exacerbated after a single dose of Shingrix vaccination

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Myasthenia Gravis Exacerbation with Shingrix Vaccine

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Clinic Stuff33This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (by-nc-nd) License. (CC-BY-NC-ND 4.0: https://creativecommons.org/licenses/by-nc-nd/4.0/)RRNMF Neuromuscular Journal 2020;1(4):33-34Myasthenia Gravis Exacerbation with Shingrix VaccineLakshmi P. Digala, MBBS andRaghav Govindarajan, MDDepartment of Neurology, University of Missouri Health Care, Columbia, MO, USA 65201 Keywords: Shingrix, Myasthenia exacerbation, Auto-immunity, Adjuvants.IntroductionShingrix is a non-live recombinant vaccine approved to prevent herpes zoster infection, and its efficacy, and safety are well studied. The risk of vaccine-related complications in myasthenia symptoms is higher with live vaccines. How-ever, Shingrix, a non-live vaccine causing exacerbation of the myasthenia symptoms, has not been reported to date. Herein, we present a case of stable myasthenia gravis that got exacerbated after a single dose of Shingrix vaccination.  CaseOur patient is a 73-year-old man diagnosed with stable seropositive generalized myasthenia gravis (MG) for the last eight years. He was on prednisone 10 mg every other day and Pyridostigmine 60 mg twice daily. He presented to the Neurology clinic with worsening ocular symptoms including horizontal diplopia worse with right lateral gaze, generalized weakness, and fatigue. He also complained about difficulty swallowing and orthopnea. 5 days before the presentation, he received the Shingrix vaccine. There was no change in medications or infections in the interim. On examination, he had fatigable ptosis with Cogan’s Sign, fatigable arm weakness, and single breath count test of 38. He was admitted and treated with IVIg (1g/kg body weight) for five days, which improved dysphagia and orthopnea but did not improve the diplopia. His dose of prednisone was increased to 30 mg every other day and Pyridostigmine 60 mg, three times a day, which improved his ocular symptoms 2 months later.DiscussionHerpes zoster (HZ) is a painful dermatomal, vesicular rash commonly seen in the elderly, also known as Shingles.1 It is caused by the reactivation of the latent Varicella-zoster virus (VZV),1 a member of the α-herpes virus family.2Shingrix is an adjuvanated non-live recombinant vac-cine for herpes zoster, which was approved by the Food and Drug Administration (FDA) in October 2017 for adults over 50 years.3It consists of glycoprotein E (gE) and an adjuvant com-ponent called AS01B, which enhances the potency, quality, and immune response’s longevity.4Vaccines, although beneficial, have proposed to be im-plicated in the development of autoimmune disorders. The definite mechanism is unknown, but one probable cause could be the vaccine components eliciting an exaggerated immune response.However, studies also reported the role of adjuvants in causing autoimmunity by simulating an immune reaction in animal models or humans similar to bacterial or viral infec-tions.5,8As stated earlier, the Shingrix vaccine consists of the glycoprotein E and adjuvant AS01B.   Adjuvants, by defini-tion, are substances that augment antigen-specific immune response.6Our patient had been stable for the past eight years and developed an exacerbation of MG 5 days after the vac-cination. Chung et al. described a case that described the possible association between vaccination and myasthenia exacerbation. They reported a case in a young woman who developed myasthenia gravis within three days of the hu-man papillomavirus vaccination.7Another vaccine associated with the onset or exacer-bation of myasthenia gravis is the recombinant Hepatitis B vaccination. Stuben described various autoimmune neu-romuscular diseases developed after the HBV vaccine.8 He described three cases, and the predisposition to auto-immu-nity is explained by their history of atopic allergy.8 Although uncommon, the temporal association of myasthenia is re-ported in three patients after Hepatitis B vaccination.8,9,10 In our case, we hypothesize that either the gE or AS01B may have led to an alteration in the host immune response, and the release of inflammatory cytokines resulted in an exaggerated T cell response and worsening of the patient’s symptoms. However, further studies are required to evaluate Shingrix vaccine safety, especially in Myasthenia Gravis patients.Corresponding author:Raghav Govindarajan MDEmail: govindarajanr@health.missouri.edu34Clinic StuffReferences1 Cunningham A.L. et al.(2016) Efficacy of the Herpes Zoster Subunit Vaccine in Adults 70 Years of Age or Old-er. N Engl J Med. 15;375(11):1019-32.  doi: 10.1056/NEJ-Moa1603800.2 Yawn BP, Saddier P, Wollan PC, St Sauver JL, Kurland MJ, Sy LS. (2007) A population-based study of the inci-dence and complication rates of herpes zoster before zoster vaccine introduction, Mayo Clin Proc, vol. 82(pg. 1341-9) doi: 10.4065/82.11.1341.3 Hesse E M., Shimbakuro T T. et al. (2019) Postli-censure Safety Surveillance of Recombinant Zoster Vac-cine (Shingrix) — United States, October 2017–June 2018. MMWR Morb Mortal Wkly Rep1;68(4):91-94.  doi: 10.15585/mmwr.mm6804a4.4 F. Maltz, B. Filder. (2019) Shingrix: A New Herpes Zoster Vaccine. P.T.  44(7): 406-409,433.5 Vered Molina, Yehuda Shoenfeld. (2005) Infec-tions, Vaccines and Other Environmental triggers of Auto-immunity. Autoimmunity. 38(3):235-45. doi: 10.1080/08916930500050277.6 E. Israeli, N. Agmon-Levin, M. Blank, Y.Shoenfeld. (2009) Adjuvants and autoimmunity, vol. 18pp. 1217-1225 doi: 10.1177/0961203309345724.7 Chung, J.Y., Lee, S.J., Shin, B. et al. (2018) Myasthenia gravis following human papillomavirus vaccination: a case report.  BMC Neurol  18,  222. https://doi.org/10.1186/s12883-018-1233-y8 Stübgen JP. (2010) Neuromuscular disorders associ-ated with hepatitis B vaccination. J Neurol Sci. 292(1–2):1–4. Doi: 10.1016/j.jns.2010.02.016.9 Biron P., Montpetit P., Infante-Rivard C., and Léry L. (1988) Myasthenia gravis after general anesthesia and hep-atitis B vaccine. Arch Int Med. 148: pp. 2685 doi: 10.1001/archinte.1988.00380120123025.10 Louzir B, Othmani S, Battikh R, Ben Abdelhafidh N, Bahri M, Taalouche L, et al. (2003) Myasthenia after hepa-titis B vaccination. Therapie. 58(4):378–9. Doi: https://doi.org/10.2515/therapie:2003059.

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Myasthenia Gravis Exacerbation with Shingrix Vaccine

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