Covid-19 Booster Vaccine Related Dermatitis: A Case Study

Case Report: A 28 year old male with a past medical history of hypothyroidism and positive ANA presented to an outpatient dermatology clinic with a diffuse pruritic rash two weeks after the administration of his first Moderna COVID booster vaccine. He denied any other accompanying symptoms such as fever or chills as well as any similar rashes to prior doses of the Moderna COVID vaccine. The rash consisted of pink erythematous minimally scaly papules, thin plaques and patches involving the left and right dorsal hands, forearms, wrists, face, neck and left shoulder. The remainder of the patient's skin including the bilateral lower extremities, the eyelids, conjunctiva and oral mucosa was clear. The patient denied any similar rashes in the past. The patient denied any allergies to medications, or food or environmental allergies. He denied any notable contact allergen exposures, including to soaps, lotions, and cosmetic products. The patient also denied any significant family history or past surgical history. The patient was on Armour Thyroid for hypothyroidism and testosterone for low levels since age eighteen. The patient was started on cetirizine 10 mg once daily for the rash with minimal improvement. Autoimmune workup for the rash was notable for an elevated anti-RNP and as the patient's past medical history included Raynaud's phenomenon and ANA positivity for ten years, the patient was diagnosed with mixed connective tissue disease (MCTD). Autoimmune conditions can often have an indolent course, where symptoms progressively develop and worsen. MCTD is an autoimmune overlap syndrome that can consist of the following three connective tissue diseases: systemic lupus erythematosus, scleroderma, and polymyositis. Millions of individuals across the world are receiving COVID vaccines to protect themselves and members of their community, and it is of utmost importance that we continue to investigate adverse events. Although of low incidence, these rare effects have the ability to impact large numbers of people within both healthy and immunocompromised populations. It is critical that we examine and document them in a rigorous manner, to ensure safe vaccine delivery and reassure the public about vaccine safety overall.

Vocal Cord Dysfunction: Do Infections Drive Disease?

Rationale: Vocal cord dysfunction (VCD) is often under-recognized and/or misdiagnosed as asthma. Although post-viral syndrome has been suggested as a contributing factor in VCD, there is little data on infectious-associated VCD and no information with COVID-19. The purpose of this ongoing, prospective registry study is to characterize risk factors contributing to VCD. Methods: Subjects age ≥ 12 years referred for VCD assessment at the time of provocation challenge-rhinolaryngoscopy were eligible to participate. Enrollment initiated September, 2021. An investigator designed questionnaire of potential risk factors for VCD including COVID-19 infection was administered with data chart collection. Results: Of 31 subjects currently enrolled, 52% (N=16) reported VCD symptoms either 1) onset following respiratory infection (N=9, 29%) or 2) worsened following COVID-19 infection (N=7, 23%). Those reporting infectious-associated VCD symptoms were more likely to report gastroesophageal reflux disease (p=0.017) with approaching significance for symptoms of throat clearing (p=0.097), chronic sinus infections (p=0.095), and age > 40 years (p=0.097) when compared to subjects who denied infectious-associated VCD symptoms. Additionally, the noninfectious-associated VCD group was approaching significance for reporting increasing number of triggers over time (p=0.051) versus infectious-associated VCD. There was no difference (p>0.05) between groups in Pittsburgh VCD Index scores, BMI, sex, co-morbid asthma, smoking status, environmental allergy history, or symptoms of shortness of breath, cough, wheezing, or throat tightness. Conclusions: Our early results suggest an important role for infectious etiologies, including COVID-19, in triggering and/or worsening VCD. Clinical awareness of these associations is warranted to rapidly address and provide appropriate therapeutic care.

Use of Telehealth Visits for Patients During the Covid-19 Pandemic in an Allergy/Immunology Network

Rationale: Telemedicine is a simple way to virtually see a doctor and determine what care a patient may need. The telemedicine platform was introduced to Greater Austin Allergy, Asthma & Immunology (GAAAI) in March 2020 to offer medical services to patients at home, especially for those with concerns due to the COVID-19 pandemic. Common allergy/asthma symptoms include runny nose, nasal congestion, and cough, which tend to overlap with COVID-19 symptoms. We hypothesized an increase in use of ICD-10 codes representing respiratory illness for telemedicine compared with in-clinic visits in an Allergy/Immunology subspecialty network during the COVID-19 epic. This study explores the use of telemedicine during the COVID-19 pandemic from 03/01/2020 through 12/31/2021 in patients seen in an Allergy/Immunology subspecialty network. Methods: GAAAI collected 35,299 patient encounters across 6 clinics from January 1, 2019 through December 31, 2021 and separated patients into the following groups: (1) All visits from 01/01/2019 through 02/28/2020, (2) In-clinic visits from 03/01/2020 through 12/31/2021, and (3) Telemedicine visits from 03/01/2020 through 12/31/2021. The data was imported into RStudio and ICD-10 code frequencies were generated for each group. Results: There was a 49% decrease in ICD-10 code use for respiratory illness for telehealth versus a 38% decrease for in-clinic visits compared with all patients seen prior to March 1, 2020. Acute infections had an 18% increase in telehealth visits and a 53% decrease for in-clinic visits. Immune deficiencies had a 220% increase for telehealth versus a 4% increase for in-clinic visits. Environmental allergy symptoms showed a 38% increase for telehealth and a 19% increase for in-clinic visits. Lastly, food allergies exhibited a 67% increase for both telehealth and in-clinic visits. Conclusions: Our original exploration was centered around patients experiencing respiratory symptoms and utilizing telemedicine to prevent spreading COVID- 19. The results display the opposite, and convey that patients were less likely to utilize a telemedicine visit when experiencing respiratory symptoms. Patients may be prioritizing their primary care physician when concerned about a potential COVID-19 diagnosis over their Allergy/Asthma specialist. It is apparent that there is still an influx of patients for nasal and food allergies for telemedicine and in-clinic visits after 02/2020. Finally, immunocompromised patients preferred to use the telemedicine platform over an in-office visit which may underline their fear of contracting COVID-19.

Recurrent Primary Spontaneous Pneumothorax Masquerading as a Congenital Pulmonary Airway Malformation in a Young Female

Introduction: Spontaneous pneumothoraxes in children are uncommon, may be idiopathic or associated with underlying pulmonary disease, and can present management challenges. We present a 12-year-old female with recurrent right sided spontaneous pneumothorax in the setting of an asymptomatic SARS-Co-V2 (COVID) infection and imaging concerning for congenital lobar overinflation (CLO) versus congenital pulmonary airway malformation (CPAM), prompting surgical intervention. Case: A 12-year-old pre-menstrual female with remote history of eczema, asthma, and environmental allergies presented from an outside facility with four-days of progressive chest pain and dyspnea on exertion and diagnosis of right-sided spontaneous pneumothorax, improving after pigtail chest tube placement. Physical exam was significant for tall thin body habitus;family history was significant for paternal spontaneous pneumothorax as an adolescent. She was incidentally found to be COVID positive. Chest plain films (CXRs) showed subcutaneous emphysema and persistent right-sided pneumothorax. Clamping trial failed, prompting removal of the pigtail and placement of 12F chest tube with resultant near complete re-expansion. On serial CXRs, a right hilar cystic lucency was newly identified. Chest CT confirmed the right upper lobe (RUL) air-filled cystic structure and abrupt narrowing of the RUL posterior segmental bronchus, concerning for CLO versus CPAM. Chest tube was successfully removed on day 6, and she was discharged home with planned follow-up. Three months later, she was readmitted for recurrent right-sided spontaneous pneumothorax diagnosed after one day of chest pain, cough, and dyspnea. Laboratory testing revealed mild leukopenia and anemia;she was COVID negative. A chest tube was placed and set to wall suction. Due to persistent pneumothorax, this was replaced with a pigtail drain on day 5. CXRs demonstrated persistent cystic RUL lung mass. With her prior COVID infection now resolved, RUL wedge resection was completed via video-assisted thoracoscopic surgery on day 8. She tolerated the procedure well and was discharged on day 10 with resolving pneumothorax. Tissue for pathology results revealed pleural fibrosis and focal hemorrhage without malignancy, most consistent with a ruptured bleb. At one week follow up, she remained stable without complications. Discussion: Pneumothoraxes in tall, thin adolescents are often categorized as primary spontaneous. Most pneumothoraxes resolve with conservative management and often do not require surgical intervention. Congenital lung malformations are a rare secondary cause in children and may be detected on CXR. Chest imaging should be carefully reviewed for congenital malformations requiring specific surgical intervention. These findings, along with the patient's clinical course, may assist in determining management.

Utilization of Allergy and Immunology Services Among Rescue Workers Exposed to the World Trade Center Disaster

RATIONALE: Over 400,000 individuals are estimated to have been exposed to the fallout of the World Trade Center (WTC) disaster. The incidence of acquired allergy and lung injury among rescue and cleanup workers exposed to the WTC fallout has been established. Briefly, rescue and cleanup workers exposed to the WTC fallout had a high incidence of allergic hypersensitivity and permanent small airways dysfunction characterized by distal airways narrowing and airway hyperresponsiveness. The current study sought to quantify the utilization of allergy/immunology services among rescue and cleanup workers exposed to the WTC fallout. METHODS: Subjects (N=65) were referred from the WTC Health Program to a multispecialty allergy/immunology and pulmonology clinic for provision of allergy-immunology specialty services. Electronic health records of all subjects were retrospectively reviewed from the date of first referral to March 2020-when routine care was interrupted due to the coronavirus disease 2019 pandemic-to quantify utilization of allergy/immunology and pulmonology services;10 subjects were excluded from analysis due to incomplete health records. RESULTS: On average, time to referral for allergy-immunology services by the WTC Health Program was 15.2 years (SD=1.7). The majority of the subjects were male (89.1%), police officers (67.3%) who never smoked (65.5%) and had no history of allergic or respiratory disease prior to being exposed to the WTC fallout. Most were found to have environmental allergies (83.6%);the most common comorbidities were allergic rhinitis (89.1%), asthma (67.3%), and chronic sinusitis (63.6%). All subjects underwent environmental allergy testing. Most subjects-35 of 55 (63.6%)-were prescribed an epinephrine autoinjector for environmental allergies. Regarding allergic immunotherapy (IT), 33 of 55 (60.0%) received IT;additionally, 7 subjects (12.7%) were determined to be IT candidates but did not receive IT. The most common monoclonal antibody therapy used in this cohort was omalizumab (18.2%). Only 11 (20.0%) and 3 (5.5%) underwent serum IgE and IgG testing, respectively. CONCLUSION: Rescue and cleanup workers referred to a multispecialty allergy/immunology and pulmonology practice from the WTC Health Program not only had a high incidence of acquired allergies to environmental allergens, but the majority were prescribed and epinephrine autoinjector and either received or were candidates to receive allergy immunotherapy. Given that hundreds of thousands of individuals were exposed to the WTC fallout and exposure is an independent risk factor for developing allergic disease, this research may have identified ways we may be falling short in providing allergy/immunology services to exposed individuals.