New Report Highlights Rare Cases of SLE Onset After HPV Vaccination

A new case report highlights the potential benefits of risk assessment for women with a family history of autoimmune diseases, such as systemic lupus erythematosus (SLE), who are considering the human papillomavirus (HPV) vaccine.

Human papillomavirus (HPV) infection is more common among people with systemic lupus erythematosus (SLE) than the general population, and the virus can play a role in the onset or worsening of the autoimmune disease.

Yet, the most common method for preventing HPV infection—vaccination—may in some cases trigger SLE for certain patients, according to a recent report.

The HPV vaccine is safe and has been approved in the United States since 2006; initially, it was approved for girls and women, and then it was broadened to include males. Uptake, however, has lagged, compared with other parts of the world, such as in Australia, where it is credited with a 92% reduction in HPV types responsible for almost 75% of cervical cancer.

The new report in International Journal of Rheumatic Diseases involved a single case at Peking Union Medical College Hospital and a series of similar cases in which patients developed SLE following HPV vaccination. The authors said the cases show it is important to assess patient risk when considering vaccination. They said the pathogenesis of SLE is complex and is believed to be related to genetic factors and epigenetic and environmental factors.

“The suggested age for HPV vaccination coincides with the age of high SLE incidence, making the relationship between the HPV vaccine and SLE incidence a notable concern,” they wrote.

In this case, a 31-year-old female reported a rash on her hand and forehead 1 week after HPV vaccination. The rash went away on its own, but it reappeared 2 months later after she received a second dose of the vaccine. In addition to the worsening rash, she also had fever, arthralgia, hair loss, and a poor appetite.

After laboratory tests, she received an SLE diagnosis and was given methylprednisolone and hydroxychloroquine, which led to improvement.

The investigators conducted a literature search of various databases for articles from January 2006 to March 2021 and identified 11 similar cases in which HPV vaccination was linked with SLE onset and laboratory data were available. In most cases, the investigators said, symptoms appeared 4 to 5 months after the second vaccination dose.

“Common clinical manifestations were fatigue, fever, arthralgia, and myalgia, with minimal involvement of vital organs,” they wrote. However, they added that there were 2 cases of lupus nephritis and 2 cases of central nervous system involvement among the group.

“Patients typically show autoantibodies for various factors in laboratory tests, including ANA [antinuclear antibodies], anti-dsDNA [anti–double-stranded DNA], and anti-SSA [anti-Ro antibodies], antiphospholipid antibodies, and hypocomplementemia,” they wrote.

In just over half of the cases, the investigators said, patients had a prior history or a family history of autoimmune disease.

All of the patients “showed rapid remission with glucocorticoid and immunosuppressive therapy and remained stable during several months of follow-up,” they said.

The investigators emphasized that clinicians ought to take a detailed personal and family history before recommending young women get the HPV vaccine. In cases where there is a history of autoimmune disease, genetic testing can be used to help clarify the patient’s risk for SLE or related diseases.

“A pre-immunization assessment of autoantibody and HLA [human leukocyte antigen] status will be a marker for at-risk individuals,” they said.

More research is needed, they added, to better understand exactly who is at highest risk of developing SLE or another autoimmune disease after HPV vaccination. Such data could result in better guidelines as to which patients are good candidates for vaccination and at which doses, they said.

They also noted that the European League Against Rheumatism recommends the vaccination for patients with rheumatic diseases in adulthood and patients with SLE during adolescence.

Allison Inserro contributed to this story.

Reference

He N, Leng X, Zeng X. Systemic lupus erythematosus following human papillomavirus vaccination: a case-based review. Int J Rheum Dis. Published online August 10, 2022. doi:10.1111/1756-185X.14404