A case of morphea following the inactivated COVID-19 vaccine

Background: The emergence of the coronavirus disease (COVID-19) prompted pharmaceutical companies to develop effective vaccines to address the problem. While studies prove the vaccines are safe, rare systemic side effects remain possible. All types can cause various vaccine-related adverse reactions which are continuously being monitored. This paper aims to highlight new data on immunologic reactions to COVID-19 vaccines. Morphea demonstrated after COVID-19 vaccination is rare. Herein, we report a case of morphea that was most likely triggered by the immune response against inactivated COVID-19 vaccine. Method(s): A case of morphea was reviewed at the clinic in a tertiary hospital in the Philippines. Result(s): A 48 year old Japanese male had no underlying co-morbidities and no previous COVID-19 infection. He had his first dose of inactivated COVID-19 vaccine, coronaVac (sinovac) with no untoward reactions. After a month, he had his second dose. One week later, the patient started to have a red plaque on his upper back, palpable, tender on palpation and pruritic. Review of systems was unremarkable. The patient denied any insect bites or skin trauma. No medications applied or taken. No known allergies to food, medications or vaccines. He is a 32 pack years smoker. No family history of any autoimmune diseases. In five months, the skin lesion insidiously progressed, thickened and now spreading to the left side of the back. The patient sought consult with a dermatologist and rheumatologist. Physical examination revealed thickened skin and subcutaneous tissue on the upper back with post-inflammatory hyperpigmentation. Work-up showed normal complete blood count, normal chest x-ray, non-reactive Hepatitis B antigen. Antinuclear antibody (ANA) was positive with 1:80 titer and nuclear speckled pattern. Anti-double stranded DNA (anti-dsDNA), anti-smith, antinuclear ribonucleoprotein (anti-RNP), anti-SSA, anti-SSB and anti-Jo- 1 were all negative. The patient's skin biopsy to the reticular dermis showed findings that are consistent with Morphea. The patient was then started on Methotrexate. Conclusion(s): People should be educated about the possible outcomes of COVID-19 vaccines. One of these are immune-related diseases, such as morphea. The underlying mechanism of morphea is multifactorial but one hypothesis highlighted that the spike glycoprotein from vaccination drives these skin reactions. Other studies demonstrated molecular mimicry to viral epitopes. Discussing this cutaneous manifestation secondary to COVID-19 vaccine stressed the importance of this clinical condition, in order to provide a proper diagnosis and therapeutic management. Although there are novel case reports of morphea induced by COVID-19 mRNA vaccine, inactivated COVID-19 vaccine-related morphea has not been reported yet.

Differential diagnosis of malformations of lymphatic vessels in dermatological practice

Lymphangiomas (LG) are uncommon, rare congenital anomalies or acquired lymphatic dilations of a benign flow that can involve the skin [1, 2]. There are main groups of lymphangiomas: 1) a superficial variant, characterized by grouped vesicles (circumscriptum lymphangioma), 2) a deeper variant in the form of a cavernous lymphangioma. The prevalence of LG may be focal or diffuse. Secondary acquired LG with a rarer frequency are known [3, 4]. LG can be one of the manifestations of a symptom complex, for example, Gorham-Stout syndrome, which is characterized by progressive osteolysis [5]. The rare occurrence of LG, clinical diversity, undulating course of congenital forms, the possibility of an acquired nature of the disease causes a high risk of diagnostic errors in establishing the final diagnosis. At the Department of Dermatovenereology, Cosmetology and Additional Professional Education of Smolensk State Medical University for the period from 2018 to 2021, 5 patients (age from 5 to 17 years) with LG were observed. Of these: in four children, the disease existed from birth, in one girl it had an acquired character and developed after covid infection [4]. Gender characteristics: 4 girls (5, 6, 12 and 17 years old) and 1 boy (9 years old). All patients are urban residents. The time to establish the final diagnosis from the moment of seeking medical help ranged from 15 months to 12 (!) years, the average value being 6.5 years. The range of diagnoses of LG 'masks': herpetic infection, molluscum contagiosum, atopic dermatitis, contact dermatitis, epidermolysis bullosa. A frequent change in diagnoses was established in the same patient. Clinical case 1. The boy is 12 years old. The debut of skin lesions from birth and progression to 3 years of age, then spontaneous regression within 4 years (without signs of dermatosis). From 7 years to the present, there has been an increase in the number of rashes. Localization: the skin of the lateral surface of the trunk. Features of the rash: flesh-colored and/or reddish- purple bubbles. A pathognomonic symptom of 'frog calves' is found. The frequent autodestructive effect on the rash provokes its subsequent progression. Family history: his father is a liquidator of the atomic catastrophe in Chernobyl. Previous diagnoses: molluscum contagiosum, herpes zoster. Clinical case 2. The girl is 17 years old. The debut of the disease from birth. Lack of progression up to 5 years of age (up to 5 years of age did not apply to dermatologists). At the age of 5, she began to engage in rhythmic gymnastics (she continues to practice professionally at the present time) and noted an active increase in the number and size of the elements of the rash. She repeatedly consulted dermatologists: diagnoses of molluscum contagiosum (laser removal), herpetic infection (courses of antiherpetic therapy without effect) were assumed. The diagnosis was established 12 years after the moment of seeking medical help. Unilateral location of the rash along the inner surface of the right upper limb with transition to the axillary region;on the right lateral surface of the body, the right inguinal-femoral fold and the inner surface of the right thigh. Focuses of a rash in the form of different sizes of vesicular elements with a tendency to lymphorrhea and oozing, areas of maceration around. Single elements with a hemorrhagic component. The patient notes an increase in the inflammatory response and vesicle lymphorrhea after each workout. Dermatoscopy: yellow-pink lacunae alternating with single dark red lacunae. Histological examination: multiple dilated lymphatic vessels in the papillary and reticular dermis. Clinical case 3. Girl 6 years old. Sick from birth. The diagnosis of LG of the genitals was established at the age of 1, 5 years. Due to the localization of the rash in the external genital area, the girl's parents (at the age of 1 month) consulted an obstetrician-gynecologist, who suggested a hemangioma and referred to a dermatologist. The disease is of a family nature her grandmother (on the maternal side) and her lder brother have similar rashes on the skin of the trunk and in the mouth. The diagnosis was verified by histological examination. The pathological process is localized in the area of the labia majora and labia minora: multiple vesicular rashes with translucent contents, easily traumatized and accompanied by itching, were found. Conclusions: LG is a multidisciplinary problem, which is caused by mimicry of manifestations, varied localization and prevalence of the rash. To verify the diagnosis, the following algorithm should be followed: 1) the debut more often at birth or in the first months of life (with the exception of acquired forms of LG);2) the nature of evolution: a stable state or slow progression in the absence of traumatic factors;3) clinical features: the formation of grouped deep vesicles that resemble 'frog eggs'. The color of the bubbles is transparent or red-purple due to the hemorrhagic component. LG lesions may have hemangioma components. It should be remembered about the frequent localization of LG on the mucous membrane of the cheeks, tongue and floor of the oral cavity, which can manifest itself as bleeding from the elements of the rash when chewing or when providing dental care;4) biopsy reveals dilated lymphatic vessels in the upper layers of the dermis.