Rheumatoid arthritis flare with extensive exfoliative skin eruption following covishield Covid-19 vaccination: A rare adverse event

INTRODUCTION

Coronavirus disease 2019 (COVID-19), caused by SARS-CoV-2, has resulted in widespread illness and mortality globally. Immunisation strategies, including the Covishield vaccine (ChAdOx1 nCoV-19), have played a crucial role in reducing disease severity and transmission. Covishield, an adenoviral vector vaccine developed by Oxford-AstraZeneca and manufactured by the Serum Institute of India, has demonstrated efficacy in preventing symptomatic infection and severe outcomes.^[1,2] Despite its benefits, there is emerging evidence that COVID-19 vaccines can, in rare cases, induce flares in patients with autoimmune diseases such as rheumatoid arthritis (RA).^[3] While post-vaccine exacerbations involving messenger RNA (mRNA) vaccines are increasingly reported.^[4,5] Less is known regarding adenoviral vector vaccines like Covishield, particularly with respect to extra-articular manifestations such as cutaneous involvement. This report details a case of RA flare with extensive cutaneous findings following Covishield vaccination, highlighting the clinical course and long-term outlook.

CASE REPORT

A 36-year-old Indian male with a 3-year history of seropositive RA, well-controlled with methotrexate, leflunomide, and hydroxychloroquine, presented with acute symptoms 48 hours following administration of the first dose of the Covishield vaccine. His initial RA presentation 3 years prior involved symmetrical polyarthritis of the small joints of the hands (metacarpophalangeal and proximal interphalangeal joints) and both knees. Previously, he had achieved sustained clinical remission, and corticosteroids had been tapered off. The patient had no prior history of psoriasis, eczema, or any other dermatological conditions. Within hours after vaccination, he developed mild arthralgia that resolved with nonsteroidal anti-inflammatory drugs (NSAIDs), but subsequently reported fever, swelling, and pain in the right knee, along with pruritic, erythematous rashes with exfoliation across the extremities.

Clinical examination revealed multiple defined erythematous plaques on the hands, forearms, feet, ankles, and knees, accompanied by symmetrical pitting oedema and overlying extensive exfoliative erythematous scaly lesions on the skin involving approximately 45% of the body surface area [Figures 1-4]. The right knee showed suprapatellar swelling, marked tenderness, warmth, and positive findings on ballottement and patellar tap. While monoarticular involvement is less common in RA, the acute exacerbation of a previously affected joint in the context of high inflammatory markers and known seropositivity supported the diagnosis of a localised flare.

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Figure 1:

Multiple well-defined hyperpigmented plaques over bilateral forearms.

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Figure 2:

Multiple well-defined erythematous plaques over bilateral lower limbs.

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Figure 3:

Oedema over the dorsal aspect of bilateral feet with scaling over toes.

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Figure 4:

Infiltrated, oedematous scaly plaques over bilateral palms.

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Investigations included ultrasonography, which confirmed a moderate effusion and synovial thickening of the right knee. Arthrocentesis yielded 35 mL of cloudy, yellow synovial fluid with a white blood cell count of 25,000/mm³ (80% neutrophils). Both Gram stain and cultures were negative, ruling out infection. Laboratory evaluation indicated elevated erythrocyte sedimentation rate (ESR) (56 mm/hr), c-reactive protein (CRP) (32 mg/L), rheumatoid factor (145 IU/mL), and anti-cyclic citrullinated peptide antibodies (>250 U/mL), with a neutrophil-to-lymphocyte ratio of 5.64. A skin biopsy was deferred because the lesions rapidly regressed following initiation of systemic corticosteroids and because the clinical morphology was consistent with a vaccine-induced reactive dermatitis.

The patient was managed with methylprednisolone 40 mg/ day and continuation of his disease-modifying antirheumatic drugs therapy, while etoricoxib was added for inflammation. Corticosteroids were tapered after two weeks. Within one month, both joint and cutaneous symptoms had resolved. Follow-up at six months revealed continued clinical remission, complete normalisation of inflammatory markers (ESR 18 mm/hr, CRP <3 mg/L), and no recurrence of symptoms. At one year, the patient remained asymptomatic on his baseline regimen and successfully tolerated additional COVID-19 booster doses. The decision to proceed with subsequent doses was based on the transient nature of the initial flare and the high risk of severe COVID-19 infection in an immunosuppressed patient. The lack of recurrence with boosters may be attributed to the patient’s stable remission and the possibility that the initial reaction was a primary immune response to the vector or novel spike protein.

DISCUSSION

RA flares following COVID-19 vaccination are rare but increasingly reported, particularly with mRNA vaccines, in both cohort studies and meta-analyses. A recent systematic review of 9,874 patients with inflammatory arthritis, including 6,579 with RA, demonstrated that while the rate of flares is slightly higher in RA compared to spondyloarthritis (9.1% vs 5.3%), the risk is not significantly increased compared to baseline, and flares are generally manageable.^[6] A national cohort noted flares in 21.3% of vaccinated RA patients, with 10.2% classified as severe, though most occurred with mRNA vaccines and were manageable with short courses of steroids or NSAIDs.^[3] A key risk factor for post-vaccine flare appears to be active disease pre-vaccination.^[2]

Unlike previously reported cases, this patient developed not only an articular flare but also striking cutaneous manifestations—an aspect rarely described after adenoviral vector vaccination. While serum sickness-like reactions can present with joint swelling and rashes, this was ruled out due to the absence of classic features such as lymphadenopathy or low complement levels, and the fact that the arthritis occurred in a previously RA-affected joint.^[4] While dermatologic reactions and autoimmune phenomena have been described with COVID-19 vaccines, the combination of RA flare with extensive exfoliative dermatitis following Covishield remains unusual and underscores critical considerations for both diagnosis and management.

Despite the initial severity, the patient's flare responded rapidly to immunosuppressive therapy, with full remission sustained over long-term follow-up and no adverse events after further COVID-19 immunisations. This positive outcome is important for clinicians, reassuring both patients and providers that such rare events are transient and do not necessitate vaccine avoidance. Continued vigilance and follow-up are prudent, especially in patients with a history of active disease, but the risk-benefit profile strongly favours ongoing COVID-19 vaccination in RA, given the risks associated with SARS-CoV-2 infection.^{[2, 6]}

CONCLUSION

This case is novel regarding the temporal relationship, pronounced cutaneous features, and a favourable long-term outcome after a Covishield-induced RA flare, which remain insufficiently described in the current literature. RA patients should be encouraged to receive the COVID-19 vaccination, with appropriate adjustments to immunosuppression and closely monitored for rare, typically manageable disease flares.