key: cord-0745343-29s9aw69
authors: Carneiro, Diogo Reis; Matos, Anabela; Morgadinho, Ana Sofia
title: Steroid-responsive aseptic meningitis after BNT162b2 SARS-CoV-2 vaccine
date: 2021-11-04
journal: Rev Neurol (Paris)
DOI: 10.1016/j.neurol.2021.10.002
sha: 98dcb702276eeb80829a13c73567378df05d4abd
doc_id: 745343
cord_uid: 29s9aw69

nan

Dear editor, Aseptic meningitis (AM) is an inflammatory disorder of the meninges that can be of iatrogenic origin. Non-steroidal anti-inflammatory drugs (NSAIDs), antibiotics or intravenous immunoglobulin (IVIg) can cause AM (1) . There is also an associated risk with certain attenuated virus vaccines, including polio, measles-mumps-rubella, and yellow fever (2) . New nucleoside-modifier messenger RNA (mRNA) vaccines against SARS-CoV-2 were recently introduced. Their safety profile is not fully understood. (Table 1) . There was no clinical relapse after suspension of corticosteroid therapy, and the patient remained asymptomatic after three months. She decided not to take the second dose of the SARS-CoV-2 vaccine.

Immune-mediated mechanisms are a possible cause of AM after vaccination, and, in our case, some points support this association. First, the temporal profile and the combined presentation with postural orthostatic tachycardia. This latter is another vaccine-induced immune syndrome that has already been reported after mRNA vaccines (3, 4) . Also, low blood lymphocyte count and CSF pure lymphocytic pleocytosis can be related to the immunogenic pathophysiology. Transient mild lymphopenia after BNT162 has been described (5) . This process is attributed to a redistribution of lymphocytes to lymphoid tissues after innate immune system stimulation. In the present case, blood lymphopenia persisted for several weeks following the vaccine, and we hypothesized that an abnormal shift of lymphocytes to the subarachnoid space occurred.

In terms of primary etiology for the AM, vaccine adjuvants, which have been recently implied in an autoimmune/inflammatory syndrome (ASIA), are a plausible explanation (6) . The BNT162b2 vaccine's adjuvant is a nanoparticlebased polyethylene glycol (PEG) stabilizer that has been implied as a trigger of ASIA syndrome in other organs (7) . AM is well-established as a non-specific reaction to certain drugs (e.g. NSAIDs, IVIg) and, along with ASIA, is frequently associated with systemic immune disorders (6, 8) . However, a recent case of AM after the COVID-19 mRNA vaccine did not find serum anti-PEG antibodies, making this relationship merely elusive (9) . The link between vaccination and remote adverse events is challenging to prove and, in most cases, remains not definitive. 10.

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