Delayed hypersensitivity reaction to hyaluronic acid dermal filler following ChAdOx1-S recombinant vaccine against coronavirus: Case report

Case report Background: Delayed hypersensitivity reactions to hyaluronic acid fillers are usually self-limiting and uncommon, and spontaneous resolution is frequent. These are presumably T-lymphocyte- mediated reactions that can be caused by flu-like infections and vaccinations. A delayed hypersensitivity reaction after hyaluronic acid filler following the mRNA vaccine against coronavirus has already been described in the literature. We wish to present a case that followed the ChAdOx1-s recombinant COVID-19 vaccine produced by Oxford/ AstraZeneca. Case report: Female patient, 61 years old, submitted to filling of the nasojugal sulcus and nasolabial fold with 1 ml of cross-linked hyaluronic acid -15 mg/ml and after 5 days filling in the lips with 1 ml of cross-linked hyaluronic acid -12 mg/ml, dermatological office, under aseptic technique and using cannulas. It evolved with ecchymosis on the lips and nasolabial folds, with spontaneous resolution after about a week. Sixteen weeks after the procedure, she received the first dose of the ChAdOx1-s recombinant COVID-19 vaccine, and 11 weeks later, the second dose. After 30 days of the 2nd vaccine dose, asymptomatic nodules appeared distributed in the upper and lower portions of nasolabial folds, in melomentonian grooves, in the supralabial region, in the upper and lower lip in the right and left lateral portions and in the infralabial region in the left lateral portion, coinciding with the topographies of the populated areas. Ultrasonographic evaluation with Doppler confirmed these findings. At the time, she denied fever or previous infectious signs or symptoms. Previously, the patient had already been submitted to the filling of the nasojugal and nasolabial folds with a hyaluronic acid-based filler (1 ml), 29 months before the current procedure, without intercurrences. After the appearance of the nodules, she underwent treatment with prednisone 40mg for 15 days, with total weaning after another 15 days, in addition to the use of levoceritizine 5 mg daily for 20 days, with partial reduction in the size of the nodules. Due to aesthetic complaints on the part of the patient, an intralesional injection of hyaluronidase was scheduled, but it was not performed at the request of the patient herself, who opted for expectant management and clinical treatment. In October 2021, the patient reported that the nodules had involuted and in December 2021 she remained asymptomatic, referring to resorption of the entire filler.

Tranexamic acid in melasma: A focused review on drug administration routes.

BACKGROUND: Melasma is a disorder of hyperpigmentation and vascularization often found in women between the ages of 20 and 40. The pathogenesis is unknown, but melasma often occurs in sun-exposed areas of the face, forearms, and back. Risk factors include family history, increased estrogen/progesterone, certain medications, and UV exposure. Melasma is typically treated with topical hydroquinone (HQ); however, it is often refractory to treatment. Tranexamic acid (TXA) is a plasmin inhibitor used off-label in the treatment of melasma. TXA can be administered orally, topically, or intralesionally. AIMS: The purpose of this review is to characterize the wide variety of TXA delivery methods for melasma treatment and the efficacy of these methods compared with traditional treatments. PATIENTS/METHODS: A comprehensive PubMed and Embase search was conducted in May 2022 using the phrases tranexamic acid and melasma. Forty-six articles were included in this review. RESULTS: Oral, intralesional, and topical TXA is safe and effective treatments for melasma. They have been studied in a variety of randomized controlled trials and have been compared with several traditional treatments. Overall, MASI scores in patients using TXA in any form improved. CONCLUSIONS: Oral TXA was found to be the most effective, especially in cases of refractory melasma; however, it caused GI upset and menstrual irregularities in many patients. The pro-thrombotic nature of this drug must be considered before safely prescribing to patients. Intralesional injections and microneedling with topical TXA were found to be effective alternatives to oral treatment. Lastly, topical TXA alone was found to be the least effective method but can be combined with other cosmeceuticals to improve outcomes. Topical TXA was also found to be better tolerated than hydroquinone, a traditional topical melasma treatment.

Intralesional delivery of glycoprotein IIb/IIIa inhibitors in acute myocardial infarction: Review and recommendations.

Plaque rupture leads to a cascade of events culminating in collagen disruption, tissue factor release, platelet activation and thrombus formation. Pro-inflammatory conditions, hyperglycemia and smoking predispose to high thrombus burden (HTB) which is an independent predictor of slow or no-reflow. In patients with acute myocardial infarction (AMI), glycoprotein IIb/IIIa inhibitors (GPI) reduce thrombus burden and improve myocardial perfusion. These agents are typically administered systemically via the intravenous route or locally via an intracoronary (IC) route. However, as higher local concentrations of GPI are associated with enhanced platelet inhibition, intralesional (IL) GPI administration may be particularly effective in cases of HTB. Modest-sized randomized trials comparing IL and IC GPI delivery have reported conflicting outcomes. Some trials have demonstrated improved coronary flow and myocardial perfusion with reduced major adverse cardiac events with IL compared with IC GPI administration, whereas others have shown no significant benefits. Furthermore, although no direct comparison has been made between IL delivery using an aspiration catheter, microcatheter or a dedicated balloon-based "weeping" infusion-catheter, improved outcomes have been most consistent following GPI administration at the site of the lesion and thrombus with the dedicated infusion catheter. This review provides an update on the role and outcomes of IL GPI administration in patients with AMI and HTB. Based on the evidence we offer an algorithm demonstrating when to consider IL administration in patients with AMI undergoing intervention. We conclude with a perspective on the management of patients with STEMI and COVID-19 in whom a prothrombotic state often results in HTB.