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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.
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Background: Urticarial reactions following Covid-19 vaccine were rarely reported and have a short self-limited resolution. However only one case of chronic spontaneous urticaria (CSU) after mRNA vaccine was observed (1). Herein, we describe an original case series of patients who exhibited a CSU after Sars-Cov- 2 vaccination. Method(s): It was a retrospective case series of patients referred to the department of Clinical pharmacology of the University of Monastir for exploration of urticaria after Covid-19 vaccination., between January 2021 and January 2022. Result(s): Eight patients (8 F /5M) were included in this study. The median patient age was 36.5 years. None of them had a medical history of CSU. Urticaria was reported in 4 patients following mRNA vaccine (BNT162b2 and Moderna). Viral vector vaccine (Oxford/ AstraZeneca) was offended in 2 cases and inactivated virus vaccine (Sinovac, CoronaVac) was reported in 2 others cases. The mean time interval between vaccination and the onset of urticaria was 28.5 hours. The first shot of vaccine was the mostly offended dose (n = 6). Urticaria was associated with angioedema in 5 patients after Oxford/AstraZenecavaccine (n = 2) and following mRNA vaccine (n = 2). One case of urticaria was associated with angioedema and dyspnea after the CoronaVac administration. Blood tests showed polynuclear leucocytosis in 37% of patients. Positive anti-thyroperoxidase antibodies, and elevated polyclonal hypergammaglobulinemia were present in one patient 3 months after receiving BNT162b2 vaccine. Total serum IgE were high in 25% of patients following BNT162b2 and CoronaVac. All patients required antihistamines and 4 cases required intravenous betametasone. The median time to symptom resolution was 3 days but urticaria rapidly reccured throughout the entire body inspite the regular use of full dose of antihistamine. Intradermal test for the vaccine excipient as well as the offended Covid-19 vaccine was carried out in 5 patients, and were negative in all of them.Currently, all patients still has the pruritic rash daily. Conclusion(s): These cutaneous reactions seem to be particularly prolonged despite the use of symptomatic drugs, as compared with of drug induced-urticaria. Consequently, careful monitoring of urticaria over an extended period of time is needed.
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Background: Eosinophilic myocarditis is a rare inflammatory cardiomyopathy with a poor prognosis. SARS-CoV-2 (COVID-19) illness has been associated with myocarditis, particularly of lymphocytic etiology. Although there have been cases of eosinophilic myocarditis associated with COVID-19 vaccination, there have been few reported cases secondary to COVID-19 illness, with the majority being diagnosed via post-mortem autopsy. Case: A 44-year-old woman with no significant medical history other than recent COVID-19 illness 6 weeks prior presented with progressive dyspnea. Patient developed acute dyspnea and diffuse pruritic rash after taking hydroxyzine. Labs were significant for mild eosinophilia. Echocardiography showed biventricular systolic dysfunction with left ventricular ejection fraction of 40%, and a moderate pericardial effusion that was drained percutaneously. She underwent left heart and right heart catheterization showing elevated biventricular filling pressures, Fick cardiac index of 1.6 L/min/m2, and no coronary disease. She was started on intravenous diuretics and transferred to our facility for further management. Her course was complicated by cardiogenic shock requiring intra-aortic balloon pump (IABP) support. Mixed venous saturations continued to decline and the patient was placed on veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support. The patient underwent endomyocardial biopsy (EMB) showing marked interstitial infiltration of eosinophils and macrophages with myocyte injury (see image). She was intubated with mechanical ventilation as well due to worsening pulmonary edema and hypoxemia. She was started on intravenous steroids with improvement of hemodynamics and myocardial function and eventually VA- ECMO was decannulated to low-dose inotropic support which in turn was ultimately weaned after 3 days of mechanical support. Conclusion(s): Eosinophilic myocarditis is a rare and under-recognized sequela of acute COVID-19 infection associated with high mortality rates. It requires prompt diagnosis and aggressive supportive care, including temporary mechanical circulatory support. There are few literature-reported cases of COVID-19 myocarditis requiring use of both IABP and VA-ECMO, none of which were used in biopsy-proven eosinophilic myocarditis, with most of these cases resulting in either fatal or unreported outcomes. Most cases of covid myocarditis required IV glucocorticoids therapy in conjunction with IVIG or interferon therapy. Here, we present a rare case of cardiogenic shock secondary to biopsy-proven eosinophilic myocarditis associated with recent COVID-19 illness with a survival outcome after temporary use of IABP and VA-ECMO support, as well as aggressive immunosuppressive therapy.Copyright © 2022
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A 59-year-old man presented with a widespread morbilliform rash after receiving the second dose of the Pfizer-BioNTech COVID-19 mRNA vaccine. He had no significant medical history and no known allergies. He did not take any regular medication. He developed pruritus without rash 4 h after his first vaccine. This resolved after 10 days without intervention. One day after his second dose, he developed an extensive pruritic morbilliform eruption on his trunk and limbs, affecting 35% of his body surface area. with no mucous membrane involvement. The rash persisted for 4 weeks after his second vaccination and he was referred to dermatology. Eosinophils were raised at 0.54 and liver function tests were normal. Antinuclear antibodies and extractable nuclear antigen were negative. Complement levels were normal. Histology showed mild epidermal acanthosis, spongiosis and subcorneal vesicles. Within the superficial to mid-dermis, there was a mixed chronic inflammatory infiltrate comprising lymphocytes, plasma cells, neutrophils and numerous eosinophils. Direct immunofluorescence was negative. He received a tapering dose of oral prednisolone with mometasone topically. Despite substantial improvement with this regimen, his rash began to worsen 2 days following discontinuation of oral prednisolone. He was still using daily mometasone on cessation of oral steroids. He was trialled on oral doxycycline for 1 month, which led to a marked improvement in the morbilliform rash. Despite improvement in the rash, the patient reported ongoing intense daily pruritus which was having a marked impact on his quality of life. He has commenced on narrowband ultraviolet B (UVB) phototherapy to treat his persistent pruritis, with good effect to date. Morbilliform eruptions have been reported as a cutaneous manifestation of COVID-19 and as a side-effect of mRNA vaccines. Proposed mechanisms for the development of skin rashes post-mRNA vaccines include viral protein expression following vaccination, prior infection with COVID-19 causing cross-reaction with the mRNA vaccine encoded antigen and vaccine components acting as haptens inducing a T helper 2 inflammatory reaction characterized by interleukin (IL)-4 and IL-13 expression. Drug-induced maculopapular eruptions typically resolve within 7-14 days on withdrawal of the culprit medication. The persistent nature in our patient may imply a complex immune response. The use of phototherapy to treat inflammatory dermatoses and pruritic conditions such as nodular prurigo is well described. The antipruritic effect of phototherapy is thought to work via modulation of both the neural pathways involved in itch and local immune cells in the skin. Our case highlights that phototherapy can be used in the treatment of cutaneous side-effects that arise after COVID-19 vaccines. To the best of our knowledge, this case is one of the first to use narrowband UVB phototherapy to treat a cutaneous side-effect of an mRNA vaccine.
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Background: Coronavirus 2019 was declared as a pandemic by the World Health Organization in March 2020. Bereft of specific treatment for the disease, vaccinations and COVID appropriate behavior have come to be the main approaches to combat the pandemic. A number of vaccines have been approved after clearing clinical trials. Hence, it is essential to evaluate the safety profile of each vaccine for ensuring optimum health of the general population. This study was conducted to evaluate the adverse events following CoviShield vaccination in a tertiary care center. Aims and Objectives: The aim of the study was to describe the pattern of adverse effects, treatment given, and comorbidities seen in healthcare workers (HCW) who reported to the adverse drug reaction (ADR) monitoring center in the department of pharmacology Government T.D. Medical College, Alappuzha, following CoviShield vaccination from January 2021 to October 2021. Material(s) and Method(s): A retrospective and descriptive study was carried out at Department of Pharmacology, GTDMCA involving all HCW who reported side effects following CoviShield vaccination in the ADR monitoring centre (AMC) in the Department of Pharmacology, GTDMCA from January 2021 to Oct 2021. Result(s): Out of 620 HCWs who reported adverse event following vaccination, majority (45%) were from the age group 21-30 years. About 83% of HCWs who reported adverse effect were women. Majority of the respondents (96%) experienced the adverse effects within 24 h. About 88% of respondents experienced these adverse effects after the initial dose alone. Commonly encountered adverse effects were fever (57%), headache (43%), myalgia (38%) etc. Hypertension (7%) was the most common comorbidity seen. Majority of the beneficiaries (70%) took paracetamol for the treatment of the adverse effect. Conclusion(s): Majority of the vaccinated HCWs experienced minor and self-limiting adverse event following immunization (AEFI) with Chimpanzee Adenovirus Oxford novel CoronaVirus-19. No serious AEFI were reported to the AMC. Despite the record speed at which the vaccine has been developed, it has shown to have a good safety profile considering the millions of doses that have been administered.Copyright © 2023 Sai Nathan R, et al.
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Pemphigus vulgaris (PV) and pemphigus foliaceus (PF) are a rare group of immunobullous disorders that can lead to high morbidity and mortality. The produced antibodies, via the aberrant B cells, are considered to be the culprits responsible for the disease development. We present a patient with PF whose disease developed after administration of the first dose of ChAdOx1 nCoV-19 (AstraZeneca) vaccination and exacerbated following the second dose of this vaccine. A 62-year-old female, with no previous history of skin diseases, received the first dose of AstraZeneca COVID-19 vaccine on 26 February 2021. She developed a generalized erythematous itchy rash in early March 2021, a few days after her vaccination. She received the second dose of the AstraZeneca COVID-19 vaccine on 14 May 2021, which resulted in significant worsening of her skin in just a couple of days, with extensive scaling and erythema. Physical examination demonstrated large erosive annular erythematous plaques on her face, trunk and limbs. No mucosal involvement was present. Histology demonstrated subcorneal pustules containing few acantholytic keratinocytes and a large number of neutrophils. Direct immunofluorescence revealed fishnet-like positivity for IgG and C3 at the intercellular epidermal spaces. Based on the characteristic clinical and histological findings, the diagnosis was confirmed as new-onset PF following COVID-19 AstraZeneca vaccination. Two patients with PV flare-up following COVID-19 Moderna and Pfizer vaccine administration (Damiani G, Pacifico A, Pelloni F, Iorizzo M. The first dose of COVID-19 vaccine may trigger pemphigus and bullous pemphigoid flares: is the second dose therefore contraindicated? J Eur Acad Dermatol Venereol 2021;35: e645-7), and a single patient with new-onset PV occurring after vaccination with COVID-19 Pfizer vaccine (Solimani F, Mansour Y, Didona D et al. Development of severe pemphigus vulgaris following SARS-CoV-2 vaccination with BNT162b2. J Eur Acad Dermatol Venereol 2021;35: e649- 51) have been reported. The main proposed mechanisms for AstraZeneca vaccine-induced pemphigus could be a hyperimmune reaction in genetically predisposed individuals, with eventual formation of anti-desmoglein antibodies. An alternative hypothesis is that vaccine components could act as foreign antigens resulting in a cross-reaction with pemphigus antigens. The close association of COVID-19 vaccination with the acute onset of pemphigus in our patient, as well as exacerbations after subsequent vaccine administration, is more than coincidental. Considering the recent pandemic with COVID-19 and the widespread administration of the COVID-19 vaccine, continued observation and documentation of true adverse events is essential.
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Pityriasis rosea (PR) is frequently proposed to result from a viral etiology. In line with the current pandemic, COVID-19 vaccines are noticed to trigger PR development. Our patient is a 23-year-old female who developed an itchy skin rash following the Pfizer-BioNTech COVID-19 vaccine. Examination showed one erythematous plaque on the left shoulder and multiple small scaly plaques of similar appearance distributed over the trunk and proximal extremities. The patient was clinically diagnosed, educated, reassured, prescribed topical mometasone ointment and oral chlorpheniramine, and was given a follow-up appointment. We report this case to increase awareness on COVID-19 vaccines as potential triggers of PR. Copyright © 2022 Journal of Dermatology and Dermatologic Surgery.
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INTRODUCTION: Prurigo nodularis (PN) is a chronic skin disorder of unknown origin which has the features of small nodules and papules along with intolerable itch leading to ulcers, bleeding and sensory neural loss in affected area. PN has quite resemblance with Alasaka in Ayurveda, which is a vata-kapha pradhan kshudra kushtha. CASE SUMMARY: A 50 years old male patient suffering from PN was being treated on the line of Ayurveda just before the beginning of COVID pandemic. Due to sudden surge of first wave of corona virus pandemic and lockdown in India, the planed virechana (purgation) therapy was interrupted. We shifted our plan to mild type of virechana and conservative therapy after a short break of 10 days at patients' home. However, the case was responded very well and significant clinical improvement was observed in Dynamic Pruritus Score (DPS), Numerical Rating Scale (NRS), Visual Analogue Scale (VAS), Verbal Rating Scale (VRS), Pruritus Severity Scale (PSS), Hamilton Depression Rating Scale (HDRS) and Dermatology Life Quality Index (DLQI).
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We discuss a case of a 63-year-old male who presented with generalized itchy papulonodular rash a few weeks after receiving a vaccination against SARS-CoV-2. The patient had a negative medical history for atopic dermatitis and other pruritic skin conditions, and clinical presentation was consistent with prurigo nodularis, which was confirmed later by tissue biopsy and microscopic analysis. The pathophysiology of this skin condition is thought to be due to an overlap between the immune and nervous systems. Due to the hypothesized involvement of the immune system in this disease, it. is presumed that the patient had a dysregulated immune response caused by his recent SARS-CoV-2 vaccination.
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Common causes of viral exanthems in Australia include herpesviruses, enteroviruses, parvovirus B19, varicella, measles and rubella viruses and mosquito-borne alphaviruses. The cause can often be diagnosed clinically from the rash distribution and morphology, confirmed only when necessary with serological or PCR tests. Most viral exanthems are self-limiting, requiring supportive care alone.
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A 27-year-old man presented to Accident and Emergency with an itchy rash over the thighs and buttocks. This followed 2 days of fever, headache and malaise. His past medical history was unremarkable and there was no regular medication use. He was unvaccinated. There was no history of previous erythema multiforme (EM) or herpes simplex virus (HSV) infection. He was febrile but otherwise haemodynamically stable. Clinically, over the thighs and buttocks there was a symmetrical rash consisting of striking urticated targetoid lesions. Some had a dusky centre and had coalesced over the thighs. There was no mucosal involvement. A SARS-CoV-2 polymerase chain reaction test was positive. Mycoplasma serology and swabs for HSV were negative. Other bloods were unremarkable. A skin biopsy from affected skin showed spongiosis and a mild dermal lymphocytic infiltrate. There was an absence of necrotic keratinocytes. He was treated with 5 days of prednisolone (30 mg) and potent topical steroids. There was complete clinical resolution of the rash in a week. In the published literature there are a small number of EM-like eruptions in the context of COVID-19 infection. Similar to our patient, skin biopsies often show features not typical of EM, including spongiosis and a lymphocytic perivascular and interstitial infiltrate (Torrelo A, Andina D, Santonja C et al. Erythema multiforme-like lesions in children and COVID-19.
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We present the case of a severe cutaneous reaction following COVID-19 vaccination. A 60-year-old white woman presented to our service with an extensive painful, pruritic rash affecting her bilateral lower limbs. This was on a background of psoriasis, psoriatic arthritis and notably inoculation against COVID-19 with the Johnson & Johnson vaccine hours prior to onset. There was no history of new medications, illicit drug use or infections. On examination, extensive palpable purpura was noted circumferentially at both lower limbs from the knee distally. Tense bullae were described at her bilateral ankles. She was apyrexial. Her cardiopulmonary and gastrointestinal examinations were normal. A punch biopsy taken from her right lower limb demonstrated findings consistent with leucocytoclastic vasculitis (LCV). Direct immunofluorescence demonstrated IgA deposits within the vasculature. IgA LCV secondary to COVID-19 vaccination was proposed on the basis of histological and clinical findings. Treatment consisted of oral steroids, oral antibiotics for secondary infection and wound dressings. Opioid analgesia and nitrous oxide were implemented for severe pain associated with dressing changes. As her urinary protein creatinine ratio was in excess of 100 mg dL-1 and microscopic haematuria was noted on urine microscopy, she was referred to nephrology. We note case reports of patients diagnosed with LCV up to 2 weeks following COVID-19 vaccination (Cavalli G, Colafrancesco, De Luca G et al. Cutaneous vasculitis following COVID- 19 vaccination. Lancet Rheumatol 2021;3: E743-4). In this case, onset of symptoms occurred within hours. While this presentation may have been coincidental, the relationship between immune complex vasculitis, COVID-19 infection (Iraji F, Galehdari H, Siadat AH, Bokaei Jazi S. Cutaneous leukocytoclastic vasculitis secondary to COVID-19 infection: a case report. Clin Case Rep 2020;9: 830-4) and vaccination (Cavalli et al.) has been reported in the literature and represents the most likely diagnosis.
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Pemphigoid gestationis is a rare autoimmune blistering disorder which typically presents in the second and third trimester of pregnancy. We present an interesting case of a localized flare of the condition following COVID-19 vaccination. A 33- year-old woman presented 2 weeks post partum with an acute onset bullous rash. This had started at week 35 of gestation, one day prior to the onset of labour. A pruritic rash developed on her right arm before becoming widespread, with urticated erythematous plaques and tense bullae. There was no mucous membrane involvement and the infant was unaffected. Skin biopsy showed a prominent perivascular infiltrate with numerous eosinophils, suggestive of pemphigoid gestationis. Uncharacteristically, direct immunofluorescence was negative. Her symptoms improved with 30 mg oral prednisolone and topical clobetasol propionate ointment. She received the first dose of the Pfizer SARS-CoV-2 vaccine 5 weeks after the onset of the rash and within days developed a flare of her rash around the inoculation site. To our knowledge, this is the first report of a flare of pemphigoid gestationis following COVID-19 vaccination. There are case reports of other autoimmune bullous disorders (bullous pemphigoid and pemphigus vulgaris) flaring and occurring de novo following mRNA COVID-19 vaccinations. COVID -19 vaccination has been rapidly rolled out and side-effects in patients with rare conditions are only becoming apparent as these patients are exposed to the vaccine. Knowledge of this side effect will enable us to anticipate it, counsel and treat our patients more effectively, and could help maintain vaccine uptake in this vulnerable patient group. (Figure Presented) .
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A 44-year-old man of Pakistani origin presented to emergency 6 days following his first dose of the AstraZeneca (AZ) SARSCoV- 2 vaccine. He developed flu-like symptoms followed by erythematous pruritic rash. Physical examination showed a maculopapular rash associated with purpura and targetoid lesions affecting his distal extremities, trunk and mucous membranes. He also had crusting and ulceration of his oral and genital mucosal areas. He had no other significant past medical history. A biopsy was taken from his right arm and sent for urgent histology and direct immunofluorescence. Histology revealed parakeratotic scale with interface dermatitis comprising basal layer vacuolation and lymphocyte exocytosis. The epidermis showed prominent dyskeratotic keratinocytes scattered throughout the epidermis. The papillary dermis showed a mild perivascular lymphocytic infiltrate including eosinophils and melanophages. Other investigations showed leucocytosis (12 × 109 L-1), high eosinophils (0.9 × 109 L-1), raised liver enzymes with alkaline phosphatase 159 U L-1 and alanine aminotransferase 172 U L-1. A full infection screen, including herpes simplex virus, SARS-CoV-2 and atypical viral infection, was negative. Immunology was also reported as negative. Based on the findings, a diagnosis of erythema multiforme (EM) secondary to AZ vaccine was made. He was treated with topical steroids and emollients, leading to resolution of his skin and mucosal areas in 4-6 weeks. Recently, there have been a few reported cases of EM in patients with COVID-19 (Jimenez-Cauhe J, Ortega-Quijano D, Carretero- Barrio I et al. Erythema multiforme-like eruption in patients with COVID-19 infection: clinical and histological findings. Clin Exp Dermatol 2020;45: 892-5) and two patients who have had the Pfizer-BioNTech vaccine [Kim M, Kim J, Kim M et al. Generalized erythema multiforme-like skin rash following the first dose of COVID-19 vaccine (Pfizer-BioNTech). J Eur Acad Dermatol Venereol 2021], but the information is limited. Our case emphasizes the need for further studies into the cutaneous adverse effects related to COVID-19vaccines.
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We report the case of a 61-year-old man referred to the dermatology clinic with a new onset of itchy rash with blisters within 2 weeks following the first dose of the Pfizer-BioNTech COVID-19 vaccine (COMIRNATY®). After the second dose of the same vaccine within 72 h, he developed a widespread rash with tense blisters with oral mucosal involvement. His medical history included obesity (body mass index 47.8 kg m-2), type 2 diabetes mellitus, hypertension and hypothyroidism. His regular medications included alogliptin (established for 3 years) and levothyroxine. There were no recent changes or additions to his drugs reported. On examination, he had extensive erythematous plaques with tense bullae and oral ulcers. Skin anti-epi basement membrane antibodies were positive, and anti-epidermal intercellular antibodies were negative. We considered the diagnosis of bullous pemphigoid (BP) on the clinical picture and indirect immunofluorescence studies. Topical treatment started with 50: 50 white soft paraffin, clobetasol propionate ointment and systemic oral prednisolone with doxycycline with reasonable disease control within 4 weeks. We were faced with a diagnostic conundrum. We postulated two possibilities: new-onset BP coincidental and unrelated to vaccination or BP secondary to the vaccine as suggested by the time-dose relationship. As the patient was established on alogliptin for 3 years, we considered it unlikely this drug had contributed to the disease onset. Case reports are now emerging of BP following vaccination with other COVID- 19 vaccines. This phenomenon has implications for future inoculation with the booster vaccine, requiring careful consideration and discussion with our patients. This case is registered on the Yellow Card scheme (Pérez-López I, Moyano- Bueno D, Ruiz-Villaverde R. Bullous pemphigoid and COVID-19 vaccine. Med Clin (Engl Ed) 2021;157: e333-4;Agharbi F, Eljazouly M, Basri G et al. Bullous pemphigoid induced by the AstraZeneca COVID-19 vaccine. Ann Dermatol Venereol 2022;149: 56-7).
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Introduction: Mycoplasma pneumoniae is a respiratory tract pathogen that most commonly causes acute bronchitis. Pneumonia is a less common manifestation. Herein we describe a patient who presented with COVID19 like symptoms after exposure but was later found to have Mycoplasma with cryptogenic organizing pneumonia (COP). Case Description: A 63-year-old lady presented to the emergency department with a cough with minimal sputum production and dyspnea for one week and a generalized itchy rash for four days. She had a recent travel history, exposure to a COVID-19 patient, and was unvaccinated against COVID-19. On admission, vitals were normal except for a heart rate of 121/min. On examination, she had a maculopapular rash involving the face, neck, back, palms, and soles (Fig A and B). Labs were significant for total leukocyte count of 12.9 X 103/ mm3, D-dimer of 1125 ng/mL which increased to 1635ng/mL in 24 hours, erythrocyte sedimentation rate of 38mm/h, and C-reactive peptide of 101.5mg/L. Chest x-ray revealed bilateral opacities worse on the right (Fig C). A CT pulmonary angiogram was negative for PE but showed bilateral peripheral opacities greater on the right side, suggesting COVID19 as the etiology (Fig D). But COVID19 PCR was negative. Due to the presence of diffuse rash, mycoplasma IgG antibodies were checked which were positive. During the hospital course, she became hypoxic requiring nasal cannula oxygenation. The patient underwent bronchoalveolar lavage (BAL) with transbronchial lung biopsy (TBLB) which revealed 60% eosinophils with COP. She was treated with IV methylprednisolone, IV ceftriaxone, and doxycycline. Her respiratory symptoms got better, and the rash significantly improved with residual hyperpigmentation. The patient was discharged on tapering doses of steroids and levofloxacin to complete 14 days of antibiotics. Discussion: Mycoplasma pneumoniae is known to cause atypical pneumonia most commonly in young children than in adolescents and adults. COP is rarely seen with it. Common dermatological manifestations include erythematous maculopapular rash, erythema multiforme. Our patient was an elderly female who presented with classic maculopapular rash and respiratory symptoms. The presence of rash and hypoxia prompted us to get BAL with TBLB which led to the diagnosis of COP and early initiation of steroids. Although open lung biopsy is considered the best approach for diagnosis, BAL with TBLB has a positive predictive value of around 95%. Symptomatic improvement in such patients is quite impressive with steroids with complete recovery in most of the patients. (Table Presented).
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Introduction Prurigo pigmentosa (PP) is an underrecognized disease in the Western population. Our aim is to describe the clinical features and follow-up outcomes of Caucasian patients diagnosed with PP. Methods This case series was conducted in the dermatology outpatient clinic of a tertiary hospital. Patients with confirmed PP from May 2020 to June 2021 were included in the study. Patient demographics, clinical features, potential triggers, treatment and follow-up data were recorded. Results A total of eight patients with female predominance were identified. The mean age of the patients was 24.5. The duration of symptoms ranged from four days to six months. All patients presented with pruritic, papular or papulovesicular lesions. Net-like hyperpigmentation was also present at the initial visit in two patients, in whom the duration of the symptoms was the longest. Lesions were most commonly located on the chest and back. Six of eight patients reported alteration of diet that potentially led to ketosis. Doxycycline 200 mg daily for two weeks led to a complete response in all six medically treated patients. Duration of follow-up ranged from 1-14 months (mean: 7.2 months). In five patients with a follow-up duration of more than three months, postinflammatory hyperpigmentation was resolved without any treatment. Only one patient had a recurrence. Conclusion PP does not seem to be a rare disease. Young women are most commonly affected, and ketosis stemming from decreased calorie intake may be the etiological factor in the majority of the patients. Dermatologists should be familiar with early signs of PP in order to minimize unnecessary therapies, recurrences and long-lasting hyperpigmentation.
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Objective: To describe the COVID-19 vaccine-related suspected adverse reactions (ADRs) reported to the Catalan Pharmacovigilance Center (CFVC) by the Bellvitge Hospital Pharmacovigilance Program (PFVHUB). Material and/or methods: This is an observational, retrospective study of suspected ADRs not stated in the Summary of Product Characteristics at the time of authorization and reported between January and October 2021. Suspected ADRs, both in healthcare professionals or their patients, were identified through spontaneous notifications made by these professionals themselves. Information was collected on patients' characteristics, adverse events, type of vaccine administered, severity, outcome and degree of accountability. Results: In total, 920 suspected ADRs were reported (894 in healthcare professionals and 26 in patients). Of these, 42 suspected ADRs among professionals were reported to the CFVC and 24 among patients. The mean age was 46.6 years, 70% were in women and 7 cases had COVID-19 previously. In 56% of the cases, the suspected ADR occurred after the first dose and in 5 cases it happened once again after the second dose. In 55 (83%) cases, the administered vaccine was Comirnaty®. The most frequent suspected ADRs were herpes zoster and simplex, oral fungal infection, paresthesia, pruritic rash, urticaria, myocarditis/pericarditis, thrombosis, cytolytic hepatitis, facial paralysis, flu-like syndrome, vertigo and thoracoepigastric vein phlebitis. In 88% of the cases, the median duration of the ADR until recovery was of 7 days (IQR 2-15). According to the causality algorithm of the Spanish Pharmacovigilance System, causality was probable or possible in 89% of the cases. Conclusions: Suspected ADRs identified by means of the PFVHUB have contributed to improve the knowledge regarding the toxicity profile of COVID-19 vaccines.
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We report a case of eruptive xanthomas in a 31 year old Caucasian man with a background history of poorly controlled Type 2 diabetes mellitus, obstructive sleep apnoea and fatty liver disease. He developed a widespread pruritic rash which started on his left arm 9 h after his first dose of the Pfizer covid vaccination which progressed to involve bilateral upper limbs, lower limbs and abdomen. However, he presented a week later with acute abdominal pain and was later admitted to ICU with pancreatitis resulting in diabetic ketoacidosis. Dermatology were consulted for management of his pruritic eruption and possible covid vaccination adverse reaction. Physical examination revealed multiple excoriated yellow to pink papules. His bloods showed a total cholesterol of 31 and triglycerides of 157. A biopsy was taken which demonstrated perivascular and periadnexal foam cells in the superficial to mid dermis consistent with eruptive xanthoma. He was commenced on fenofibrate to manage his hypertriglyceridemia and insulin to manage his diabetes. This case highlights the rarity of eruptive xanthomas and that it can go unrecognised or misdiagnosed if not considered. Clinicians should consider a biopsy to confirm the diagnosis and consider differentials of Non-Langerhans cell and Langerhans cell histiocytosis, disseminated granuloma annulare and sarcoidosis. Eruptive xanthomas are lipid deposits in the skin in the context of high triglycerides >20 mmol/L. They are characterised by firm 2-5 mm papules that commonly involve the extensor surfaces. The papules can be pruritic or tender. The xanthomas usually resolve within two weeks of normalisation of triglyceride levels, as observed in this patient. Effective treatment options include dietary modification and lipid lowering medication such as fenofibrate. In refractory cases, surgical excisions, cryotherapy and ablative lasers such as Er-YAG and CO2 have been reported . Clinical photos and histology will be presented for discussion.