Immune-mediated hepatitis with the Moderna vaccine, no longer a coincidence but confirmed

To the Editor:

Case description

A 47-year-old Caucasian man, previously completely well, received his 1st Moderna vaccine dose on the 26 April 2021. He noted malaise and jaundice 3 days after. Investigations on the 30^th April showed serum bilirubin 190 μmol/L (normal 0-20), alanine aminotransferase (ALT) 1,048 U/L (normal 10-49), alkaline phosphatase (ALP) 229 U/L (normal 30-130), albumin 41 g/L (normal 35-50). Blood count, renal function and international normalized ratio (INR) were normal. Liver function tests (LFTs) last checked 4 years previously were normal. He denied paracetamol use and reported minimal alcohol intake. Ultrasound scan, CT thorax, abdomen and pelvis and MRI pancreas performed to exclude malignancy, showed no significant findings. Serum IgG was raised at 25.1 g/L (normal 6-16), IgM 2.2 g/L (0.5-2) and serum was positive for anti-nuclear antibody. Serological tests for HAV, HBV, HCV, HEV, EBV and CMV were negative.

His jaundice faded and LFTs improved: bilirubin falling on 25^th June to 69 μmol/L and ALT to 332 U/L. The patient received his 2^nd Moderna vaccine dose on the 6 July 2021 (despite reporting the jaundice to the vaccination centre) and the jaundice returned a few days after. Blood tests on 20th July found bilirubin 355 μmol/L, ALT 1,084 U/L and a raised prothrombin time (PT) of 18.4 seconds. After liver biopsy on the 21st July 2021, prednisolone 40 mg/day was commenced and he was transferred to our service.

On examination, he was alert, deeply jaundiced, with hepatomegaly but no ascites. Repeat abdominal ultrasound showed a mildly fatty liver, patent portal and hepatic vein flow, with no ascites. Review of the liver biopsy showed acute active hepatitis: widespread areas of bridging necrosis, marked interface hepatitis, lymphoplasmatic inflammation including eosinophils, ballooned hepatocytes, multi-nucleated giant cells, and emperipolesis (Fig.1). There was minimal fibrosis, Ishak stage 1. The pattern of injury on histology was consistent with acute hepatitis, with features of autoimmune hepatitis or possible drug-induced liver injury (DILI), triggering an autoimmune-like hepatitis.

Prednisolone 40 mg/day was continued and LFTs improved (Fig. 1). He was discharged on prednisolone and on follow-up, blood tests continue to improve, and PT normalised within 2 weeks.

I've also heard multiple reports about the massive upturn in the numbers of shingles cases being reported across all the Covid vaccines. There was a fascinating podcast I listened to where a doctor said that at medical school they were taught that if a patient presented with shingles, they were to run a full set of bloods to look for something bad going on, namely cancer, but they obviously didn't say this to the patient. 

He said that almost everyone is exposed to the Herpes Zoster virus all the time and because we all have chickenpox as children, the virus lives on in our systems but our immune response keeps it under control. Most people don't get shingles. But in those who do, it's an indication that their immune system is severely stressed and so the Herpes Zoster has reignited. He said that most often this is due to cancer or something else as serious, hence the blood tests. 

Well he went on to say that since the introduction of the Covid vaccines, doctors all over the place have noticed that suddenly lots of people are presenting with shingles. This doesn't normally happen after a normal vaccines so what's going on. 

On a personal note, I'll tell you that my cousin developed shingles after his second jab. He had shingles really badly and struggled to recover. 3 weeks later he developed a lung infection and was taken to hospital and 5 weeks later he died there. He was 58. That was just before Christmas.

Well I think the potential adverse side effects of the vaxx is without a doubt still well within the uphill rise of the learning curve. I'll wager no one on here had ever heard of the vaxx giving anyone hepatitis.