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\begin{document}

\title{Scleritis Following the booster shot of inactivated COVID-19 (Sinopharm)
Vaccine in a 52-year-old Woman}



\author[1]{Kimia Jazi}%
\author[2]{Mahnaz Rahimi}%
\author[3]{Fatemeh  Hasani}%
\author[2]{Maryam Shirmohammadi}%
\author[4]{Maryam Masoumi}%
\affil[1]{Qom University of Medical Sciences}%
\affil[2]{Qom University of Medical Sciences and Health Services School of Medicine}%
\affil[3]{Golestan University of Medical Sciences and Health Services}%
\affil[4]{Qom University of Medical Sciences and Health Services}%


\vspace{-1em}



  
  \date{May 25, 2024}


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\textbf{Scleritis Following the booster shot of inactivated COVID-19
(Sinopharm) Vaccine in a 52-year-old Woman}

Kimia Jazi\textsuperscript{1}, Mahnaz Rahimi\textsuperscript{1}, Fatemeh
Hasani\textsuperscript{2}, Maryam Shirmohammadi\textsuperscript{1},
Maryam Masoumi\textsuperscript{3*}

\textsuperscript{1}Student Research Committee, Faculty of Medicine,
Medical University of Qom, Qom, Iran

\textsuperscript{2} Golestan Research Center of Gastroenterology and
Hepatology, Golestan University of Medical Sciences, Gorgan, Iran

\textsuperscript{3} Clinical Research of Development Center, Shahid
Beheshti Hospital, Qom University of Medical Sciences, Qom, Iran

\textbf{Corresponding Author:}

\textbf{Maryam Masoumi,}

Clinical Research of Development Center, Shahid Beheshti Hospital, Qom
University of Medical Sciences, Qom, Iran

Email: m.masoumiy@gmail.com

\textbf{Abstract}

\textbf{Background} : The only way to mitigate the spread of COVID-19
pandemic, were vaccines. Although effective in decreasing the rate and
severity of the disease, there has been also considerable adverse
events. Since the birth of vaccines, adverse reactions undeniably
accompanied vaccines immunity and COVID-19 vaccines are no exceptions.
In this report, we aimed to evaluate a rare reaction.

\textbf{Case presentation} : We report a 52-year-old woman, presenting
with scleritis following the third dose of Sinopharm vaccinations. She
had no significant past history of any disease or any similar reactions
after previous doses. No significant positive point was found during
evaluations. She was prescribed a tapering dose of prednisolone (30mg at
the start), along with azathioprine (50mg/day) to control the episode.
After two weeks, the scleritis completely resolved.

\textbf{Conclusion:} Adverse events of vaccines could be a sign of an
undiagnosed autoimmune disease. As mentioned in this case, clinicians
must carefully assess patients with ocular adverse events as they are
highly associated to undiagnosed autoimmune diseases.

\textbf{Keywords}

scleritis; COVID-19; COVID-19 vaccine; adverse events; case report

\textbf{Key Clinical Message:} Although vaccination is necessary to
prevent infectious diseases, there are also rare adverse events that
could be a sign of an undiagnosed autoimmune disease. Clinicians must
carefully assess patients to rule out possible underlying diseases.

\textbf{Introduction}

In December 2019, world faced the outbreak of COVID-19 of which the
SARS-CoV-2, was known as the causative pathogen. As the virus found its
way world spread, in beginning of march 2020 WHO officially declared the
disease as a pandemic (1).

Inevitably, massive vaccination became the only way to prevent and
control the unleashed pandemic (2). In almost two years 155 vaccine
candidates were developed which 23 of them were authorized fallowing
different strategies (inactivated, mRNA, viral vector,
nanoparticle-based peptide vaccines, etc.). All authorized vaccines have
shown promising efficacy; however, the AEs and SAEs remained an unknown
challenge (3). The most common AEs were injection site pain or
tenderness, fatigue, headache, rash, fever, chill, as well as myalgia,
and arthralgia (4). Moreover, thrombosis and thrombocytopenia,
myocarditis or pericarditis, inflammatory myositis, and autoimmune
diseases were frequently reported SAEs (4, 5). To date few, studies have
reported cases of ocular inflammatory AEs after the first or second dose
of vaccination, including white dot syndrome, pan uveitis, choroiditis,
along with scleritis and scleritis (6, 7).

Herein, we reported a case of 52-year-old woman presented with simple
scleritis following third dose of Sinopharm COVID-19 vaccination.

\textbf{Case Presentation}

A 52-year-old woman presented with redness in both eyes for one week
(Figure1). She had no history of hypersensitivity reaction or similar
events. The patient first developed right eye redness 3 days following
the third dose of inactivated Sinopharm vaccine (BBIBP- CorV), which
spread to the left side 3 days after. In physical examination, the
patient's vital signs were normal and stable, without respiratory
distress and fever. No signs of lymphadenopathy or splenomegaly were
detected. The patient's neurological examination was unremarkable. The
ophthalmic evaluation showed no signs and symptoms of eye discharge,
pain, photophobia, and itching. Besides, the patient had a remarkable
past medical history of pterygium on her left eye conjunctiva in the
past year, well controlled. The oculist reported her visual acuity to be
20/20 OU before. Slit lamp examination showed anterior diffused
scleritis with negative phenylephrine test results. There was no sign of
inflammation or the existence of cells.

Laboratory results showed elevated levels of CRP, and ESR to be 9.1
(positive: \textgreater{}9), and 39 (positive\textgreater{}30).
Moreover, liver function tests, kidney function tests, albumin, total
protein, PANCA and anti-MPO, CANCA and Anti PR3, FANA, ds cryoglobulins,
C3, C4, anti-dsDNA, serology tests for HCV, HBV and HIV were negative or
normal (Table 1). Also, the results of stool examination and urinalysis
did not reveal any findings in favor of renal disorders or infectious
diseases.

Radiological evaluation with a CXR and computed tomography scan did not
show any notable findings. Echocardiography and electrocardiogram showed
no abnormal findings without any systolic or diastolic dysfunction and
with normal EF. EMG-NCV were normal.

By merging all the information obtained from the patient's symptoms and
clinical evaluations, and the recent COVID-19 vaccine, scleritis as an
autoimmune reaction induced by Sinopharm COVID-19 vaccination was
approved after all assessments.

She was administered a tapering dose of prednisolone (30mg at the
start), followed by azathioprine (50mg/day) to control the episode.
After two weeks, the scleritis completely resolved.

\textbf{Discussion}

Episcleritis has been previously found in a patient confirmed with
COVID-19 infection (8, 9). In this report, we presented a case of
scleritis after the third dose of COVID-19 vaccination with inactivated
Sinopharm vaccine. Recently, Pichi and colleagues reported four cases
scleritis and episcleritis following the first dose of COVID-19
Sinopharm vaccination (10). There has been few reports of mild scleritis
or episcleritis caused by live virus vaccination previously (11).

Regarding various reports of ocular adverse events induced after
vaccination, COVID-19 vaccination-associated scleritis would not be
exempt in surprising. The pathogenesis and mechanism of this immune
response, remains the question. The most frequently proposed mechanism
include molecular mimicry between scleral and vaccine peptides as well
as hypersensitivity due to antigen-specific cell and antibody reactions
(12). Moreover, although safe in most of the population, vaccine
adjuvants that were added to achieve the desired protection, led to
autoinflammatory syndromes particularly connective tissue disorders due
to different nucleic acid metabolism (9, 13, 14). Noteworthy,
inactivated COVID-19 vaccines stimulate T helper 2 cell reactions
causing an increase in inflammatory (15). The addition of alum as an
adjuvant aggravated immunopathologic reactions (16).

The genes for immunity, inflammation, and coagulation are part of X
chromosome, so we may suspect that viral interactions associated with
human genes could induce an abnormal immune response in COVID-19.
Besides, according to Manzo et al., the presence of excess antigen and
the formation of relatively resistant soluble antigen-antibody immune
complexes after exposure to SARS-CoV-2 may cause persistent inflammation
in organs (17). There are several reported cases of ocular inflammation
and related conditions following COVID-19 vaccination. These include
anterior uveitis (7, 18), scleritis (7), episcleritis (7), multiple
evanescent white dot syndrome, Vogt-Koyanagi-Harada disease (19),
panuveitis (20), choroiditis (21), and central serous chorioretinopathy
(22). Most cases were successfully treated with corticosteroid therapy,
including topical, intravitreal, and/or systemic administration, and
many patients achieved complete recovery of their baseline visual
acuity. A case series of orbital inflammation following mRNA vaccines
was also described, with all cases successfully treated with oral
prednisolone (23). It is important for healthcare providers to be aware
of these potential ocular reactions to COVID-19 vaccination and to
monitor patients closely for any signs or symptoms of ocular
inflammation or related conditions.

As mentioned, our patient didn't show any serious reaction to previous
doses of inoculation until the first booster. These reactions were found
to be induced by activation of the secondary immune response; the memory
cells (24). Comparing to the first and second doses of vaccinations,
Rahmani et al. Reported that booster doses are more probable to
stimulate rare AEs including neurological symptoms (25). Moreover,
authors suggested hormonal, genetic, and behavioural factors along with
the time between the primary cycle to the first booster dose. The more
the time between the booster dose and the first administration, the
higher the immunogenic effect after the third shot (25). Consequently,
further studies could elucidate the proper time of the booster
inoculations, particularly for high-risk patients in order to prevent
serious reactions.

Vaccine-associated maladaptive immune response becomes more important in
patients with autoimmune diseases. A study demonstrated that ocular
inflammatory AEs following vaccination could be the first presentation
of an undiagnosed autoimmune disease (26). Thus, there should be further
assessments in patients presenting with ophthalmologic inflammatory
reactions following COVID-19 vaccination.

\textbf{List of abbreviations}

COVID-19: coronavirus disease 2019

SARS-CoV-2: Severe Acute Respiratory Syndrome Coronavirus-2

WHO: World Health Organization

AEs: Adverse Events

SAEs: Serious AEs

PANCA and anti-MPO: perinuclear anti-neutrophil cytoplasmic antibodies

CANCA and Anti PR3: anti-neutrophil cytoplasmic antibodies

CXR: Chest X-ray

EMG-NCV: Electromyography-nerve conduction velocity

AST: aspartate aminotransferase

ALT: alanine transaminase

WBC: White blood cell

RBC: Red blood cell

Hb: hemoglobin

MCV: mean corpuscular volume

MCH: mean corpuscular hemoglobin

MCHC: Mean corpuscular hemoglobin~concentration

ESR 1h: Erythrocyte Sedimentation Rate in one hour

CRP: c-reactive protein

Anti B2-GLP1 antibody: anti-b2glycoprotein antibody

ACA: anti-cardiolipine antibody

LA antibody: lupus anticoagulant

dRVVT: Diluted Russell Viper Venom Time

aPPT: activated partial prothrombin time

Anti-dsDNA: anti- double-stranded DNA

C3/C4: complement~3/4

CH50: total hemolytic complement

FANA: fluorescent antinuclear antibody

Anti-Sm/RNP antibody: anti-Smith/antinuclear ribonucleoprotein antibody

HLA: human leukocyte antigen

HCV, HBV and HIV

\textbf{Declarations}

\textbf{Ethics approval and consent to participate}

Not applicable

\textbf{Consent for publication}

Written informed consent was obtained from the participant in this study
for all the information and images.

\textbf{Availability of data and materials}

All data generated or analyzed during this study are included in this
published article.

\textbf{Competing interests}

The authors declare no competing interests.

\textbf{Authors' contributions}

K.J analyzed and interpreted the patient data and revised the article
critically for important intellectual content, M.R performed associated
examinations, F.H and M.S were major contributors in writing the
manuscript, M.M drafted the article and approved the version to be
published

\textbf{Acknowledgements}

Not applicable

\textbf{Funding}

Not applicable

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Predictor of Predisposition to Autoimmunity. Cureus. 2020;12(3):e7451.\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
Test, Unit\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
Result\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
Reference Range\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Blood biochemistry\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
AST, U/L\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
17\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Up to 35\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
ALT, U/L\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
15\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Up to 45\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Uric Acid, mg/dL\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
4.3\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Male 3.4-7 Female 2.4-5.7\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Hematology\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
WBC, \selectlanguage{greek}µ\selectlanguage{english}L\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
8800\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
4000-11000\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
RBC, 10\^{}6/\selectlanguage{greek}µ\selectlanguage{english}L\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
4.84\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
4.2-6.3\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Hb, g/dL\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
12.6\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
12-16\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Hematocrit, \%\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
40.5\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
30-45\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
MCV, fL\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
83.67\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
80-100\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
MCH, pg\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
26.03\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
27-32\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
MCHC, g/dL\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
31.11\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
33-38\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Platelet, \selectlanguage{greek}µ\selectlanguage{english}L\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
363000\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
150000-450000\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Neutrophil, \%\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
40\%\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
--\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Lymphocyte, \%\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
25\%\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
--\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Urine 24hr/ Pr, mg/24hr\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
147\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
24-141\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Urine 24hr/ Volume, g/24hr\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1200\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
--\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Urine 24hr/Cr, mg/24hr\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
624\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
600-1800\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Serology\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
ESR 1h\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
39\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
positive: \textgreater{}30\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
CRP quantitative\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
9.1\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
positive: \textgreater{} 6\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Anti B2-GLP1 antibody (IgG)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
7\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
positive: \textgreater{}20\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Anti B2-GLP1 antibody (IgM)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1.7\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
positive: \textgreater{}20\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
ACA IgG\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
24\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
positive: \textgreater{}=12\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
ACA IgM\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1.5\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
positive: \textgreater{}=12\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
LA antibody (dRVVT)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
34\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
direct :25- 45\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
LA antibody (aPTT)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
30\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
after mixing: 25-45\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Anti-ds DNA\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
6.6\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
positive: \textgreater{}=100\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
C3\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
165\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
90-180\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
C4\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
54\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
10-40\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
CH50\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
90\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
positive: \textgreater{}=90\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
FANA\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
negative\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Up to 1/100\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
C-ANCA\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
negative\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Up to 1/10\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
P-ANCA\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
negative\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Up to 1/10\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Anti-Sm/RNP antibody\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.1\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Up to 20\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
HLA-B27\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
negative\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
--\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
HLA-B5\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
positive\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
--\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
HLA-B51\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
negative\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
--\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Figures, tables and additional files}

\textbf{TABLE 1} Laboratory Test Results

\textbf{FIGURE 1:} Unilateral anterior scleritis following COVID-19
Sinopharm vaccination three days after the third dose\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

