Safety of the Vaccine against Sars-Cov-2 in Patients with Systemic Lupus Erythematosus: Data from the Safer Study

Objectives: Systemic lupus erythematosus (SLE) is an autoimmune disease which presents infections as one of the most frequent complications, including more severe outcomes of Coronavirus disease 2019 (COVID-19). Immunization of these patients has been strongly recommended, however, data on safety are still scarce. In this study we evaluate the safety after vaccination against SARS-CoV2 in patients with SLE. Method(s): Safety and Efficacy on COVID-19 Vaccine in Rheumatic Disease - the 'SAFER' study, is a longitudinal Brazilian multicenter phase IV study. In this study patients with SLE (according to the 2019 ACR/EULAR criteria), older than 18 years who received vaccination against SARS-CoV-2 CoronaVac (Inactivated SARS-CoV-2 Vaccine), ChadOx-1 (AstraZeneca) and BNT162b2 (Pfizer-BioNTech) were included. The evaluation of adverse events (AEs) was done by telephone contact, symptom diaries and a face-to-face visit on the 28th day after each dose. Patients were followed up also by disease activity, assessed using SLEDAI-2 K score. Result(s): A total of 367 individuals with SLE were included, 207 received CoronaVac, 128 received ChadOx-1 and 32 received BNT162b2. Ninety percent of the subjects were female with a mean age of 37 years. About 50% (182) of patients were using oral glucocorticoids and azathioprine was the most frequent immunosuppressive therapy. Regarding disease activity parameters, 38%(140) of patients had zero SLEDAI-2Kat baseline and 41%(147) had zero SLEDAI-2 K 28 days after the 2nd dose. After the first and second dose the most frequent AEs were pain at injection site (58%/44%), headache (48%/33%) and pruritus (42%/37%). Comparing the three vaccines, after the first dose, local symptoms, myalgia, and fever were less frequent in patients who received CoronaVac (p alpha 0.001) as well as headache, tiredness (p = 0.001) and arthralgia (p = 0.003). After the second dose, only local symptoms such as pain at the application site and thickening of the skin around the application site were less frequent in the CoronaVac group (p alpha 0.05). Headache, tiredness, musculoskeletal symptoms and fever were more common in patients receiving AstraZeneca. No serious adverse events were reported regardless of the vaccination schedule used. Conclusion(s): This study suggests that vaccines against SARS-COV-2 are safe in SLE patients. Neither severe AEs were reported nor worsening of disease activity were reported. Comparing the different vaccines, CoronaVac had fewer adverse events.

Palmoplantar inflammation with a broad differential diagnosis made clear upon patch testing

A 51-year-old woman presented to our service with a 2-year history of severely painful, thickened skin of her bilateral hands and feet. She advised of considerable skin pain on mobilizing. She intermittently applied acrylate nails. This was on a background of chronic urticaria, asthma and allergic rhinitis. She described a positive family history of psoriasis. On examination, there was marked hyperkeratosis with welldemarcated erythema on the central palms and entire fingers with deep fissuring and scale. Similar finding were noted on the soles of the feet particularly affecting the heels, arch and also the tips of the toes. The morphology of the lesions favoured psoriasis, but the differential diagnosis included chronic hand dermatitis. She was referred for topical psoralen + ultraviolet A (PUVA) and patch testing to standard battery and acrylates. Treatment with topical PUVA was discontinued and patch testing lists were cancelled as a result of the emergence of COVID-19 in Ireland. Topical therapy of clobetasol propionate was initiated. On follow-up review, the appearances of her feet and hands had deteriorated significantly. She was commenced on acitretin 10 mg once daily, which was escalated to 20 mg 2 months later. Clinical improvement was noted, but appearances deteriorated once again following the application of acrylic nails. Further history revealed the patient had assisted with the application of acrylic nails to clients years prior to her initial review. Patch testing took place 18 months after initial review due to outpatient list cancellations secondary to the COVID-19 pandemic. Upon review 48 h after the application of the (METH) Acrylate Series, the patient was found to have a +2 reaction to 2- hydroxyethyl methacrylate and a further +2 reaction to 2- Hydroxypropyl methacrylate. At her 96-h review, both reaction sites were marked at +1. Following complete avoidance of acrylates, the palmoplantar inflammation entirely resolved. This case highlights the importance of a detailed clinical history where contact dermatitis is considered. In our patient's case, the clinical history and examination of the palmoplantar eruption combined with the first-degree family history of psoriasis were highly suggestive of a diagnosis of psoriasis. The episodic severe flares and its refractory nature to treatment raised suspicion for allergic contact dermatitis. Dermatologists should remain alert for potential contact allergens in cases of severe palmoplantar psoriasis. A further area for consideration is the deleterious effect the COVID-19 pandemic had on the successful diagnosis and treatment of dermatological patients through the cancellation of outpatient services.

Abdominal Haematomas following subcutaneous heparin injections in COVID19 patients, Food for thought in daily practice

Introduction: Abdominal haematomas are an uncommon complication of subcutaneous injection of low molecular weight heparin (LMWH) although the latter is widely administered. Aim(s): To review clinical cases of abdominal haematomas following subcutaneous LMWH injection, discover the root causes and identify appropriate solutions to improve clinical practice. Material(s) and Method(s): Retrospective case review of all clinical cases linked to abdominal haematomas secondary to LMWH injection. Result(s): Between 09.2020-01.2022, 760 patients were admitted in our Department due to COVID19 pneumonia. 4 cases of abdominal haematomas were reported (all females, mean age 70.5 years). All patients received therapeutic LMWH(3 for atrial fibrillation). All patients presented haematomas on rectus abdominis muscle and subsequently in the pelvic area. All patients presented with haemodynamic instability and required blood transfusions. Clinical outcomes included death (1), nephrostomy (1) (due to haematoma expansion and ureteral obstruction) and prolonged hospital stay by 12 days (2). Route cause analysis revealed improper injection technique in the following order;narrow abdominal margins, no skin folding, injection speed<10secs. Solutions were identified and followed including multidisciplinary nursing re-training that was implemented across the board and was accompanied by continuous monitoring of nursing practice. Conclusion(s): The rare complication of abdominal haematomas following LMWH was closely reviewed in our department and was turned into an opportunity to reconsider daily clinical practice, to contribute to quality improvement and improve patient safety.

Eosinophilic fasciitis triggered by intensive exercise

A 59-year-old white female who was previously fit and well, developed gradual tightening and thickening of the skin on her forearms progressing to the abdomen, chest and lower legs associated with restricted movement. She also noticed bruise-like patches on her trunk. There were no systemic symptoms and no history of Raynaud syndrome. Since the beginning of the COVID-19 lockdown, the patient had engaged in increasing amounts of exercise compared with normal;this included yoga once weekly for 75 min, high-intensity interval training for 20 min on alternate days, running three times weekly for 45 min, lifting 2.5 kg weights for the arms every day and regular long walks. Examination showed a 'groove' sign on her forearms and a peau d'orange appearance of the skin with a woody induration and hardness on palpation. Symmetrical and circumferential involvement on the forearms and lower legs and bruise-like indurated patches on the abdomen were noted. Differential diagnoses included eosinophilic fasciitis (EF), morphoea, EF/morphoea overlap, scleroderma, scleromyxoedema and nephrogenic systemic fibrosis. Blood investigations showed an eosinophilia of 1.2 x 109 cells L-1, erythrocyte sedimentation rate of 31 mm h-1, a C-reactive protein of 20 mg L-1 and negative autoimmune and viral serology. She underwent two incisional biopsies down to fascia. The first was taken from the back, which showed an interstitial inflammatory cell infiltrate composed of lymphocytes, plasma cells and very occasional eosinophils. The subcutaneous septa were minimally thickened. The second biopsy taken from the left forearm showed striking thickening of the subcutaneous septa, with an associated inflammatory cell infiltrate, composed predominantly of lymphocytes and plasma cells. This process was deeper and more established than that seen in the biopsy from the trunk. The appearances were clearly those of a sclerosing process of the dermis and subcutis and consistent with eosinophilic fasciitis. Our diagnosis was EF with morphoea overlap and she was treated with oral methotrexate 15 mg weekly and oral prednisolone 50 mg once daily (weight 60 kg), reducing the dose by 5 mg every 2 weeks. An 80% improvement was seen in functionality within 3 months, but the skin remained tight and thickened and therefore the patient was referred for phototherapy [ultraviolet A 1 (UVA1)] as combination therapy. We present a rare case of EF, which appears to have been triggered by intensive exercise. Other causes include insect bites, radiation, infections (Mycoplasma and Borrelia) and paraneoplastic. Haematological associations have been seen, including aplastic anaemia and lymphoma. Treatment options for EF include prednisolone, UVA1/psoralen + UVA, immunosuppressive systemic agents (including ciclosporin and methotrexate), biological agents (including infliximab and rituximab) and physiotherapy.

Association between Handgrip Strength, Skinfold Thickness, and Trunk Strength among University Students.

OBJECTIVES: The main goal was to explore the relationship between hand grip strength (HGS), the thickness of the skinfold at multiple sites, and the trunk flexor (TF) and extensor (TE) muscle strength among healthy participants. METHODS: We employed a cross-sectional design and randomly recruited 40 participants. Ultimately, only 39 participants were included. First, measurements for demographic and anthropometric variables were carried out. After that, the evaluation of hand grip strength and skinfold was performed. DATA ANALYSIS: Descriptive statistics were used to explore the amount of interaction between the smoking and nonsmoking groups, and a repeated measures analysis of variance was employed. Furthermore, associations between dependent and independent variables were discovered through a multiple linear regression model. RESULTS: The participants had a mean age of 21.59 ± 1.19 years. The results of the repeated measures analysis of variance validated an acceptable interaction between the trunk and hand grip strength at a significance level of p < 0.01, further emphasized by their moderate association (p < 0.05). Multiple regressions between TE, TF, the independent variables T score, height, and age were also significant (p < 0.05). CONCLUSIONS: The trunk muscle strength can be used as a health indicator for comprehensive evaluation. The present study also found a moderate relationship between hand grip strength, trunk strength, and T score.

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.

SEVERE ALLERGIC ERYTHEMATOUS REACTION POSTMESSENGER RNA-BASED COVID-19 VACCINE

SESSION TITLE: Issues After COVID-19 Vaccination Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Covid 19 pandemic has infected 125 million people so far (1). The development of safe and effective vaccines is crucial to lessen the impact of SARS-COV 2 on global health. Some adverse events of the covid 19 vaccination have been reported including few dermatological reactions. We report a case of severe allergic erythematous drug reaction that occurred 3 days after the second dose of messenger RNA (mRNA) Pfizer vaccine. CASE PRESENTATION: A 42 year old female with past medical history of Grover's disease and Multiple Sclerosis presented to the Emergency department from the nursing home with complaints of erythematous, scaly, painful rash that occurred 3 days after the second dose of mRNA covid 19 vaccine. Patient states she had a generalized rash after the first dose of vaccine but it resolved spontaneously and did not require treatment. This time the rash started on the scalp and gradually progressed to the rest of the body. It was associated with severe itching, burning and serosanguinous discharge. Patient did not report any change in medication, use of new detergent or contact with an offending agent. The patient denied fever, chills, nausea, vomiting, diarrhea, constipation, abdominal pain, chest pain or palpitations. She had no history of similar complaints in the past. On physical examination, she was afebrile and hemodynamically stable but in severe distress due to pain. The rash covered 95% of the body surface area and was more severe around the mouth, in the axilla, neck and the inframammary area. Erosions could be seen in the skin folds with serosanguinous discharge. The laboratory results were positive for eosinophilia with absolute eosinophil count of 0.7. Remaining laboratory results were within normal limits. The pathology report for the erythematous rash was consistent with drug reaction. A slight vacuolar degeneration along the dermal epidermal junction with few apoptotic keratinocytes were noted. A compact horn and band-like lymphoid infiltrate were also noted. The patient was started on high dose steroids, analgesics and antihistamines. Petroleum gel impregnated gauze was used for dressing. She was placed in the intensive care unit for careful monitoring. Her rash resolved gradually and her symptoms improved. DISCUSSION: mRNA vaccines are associated with type 1 interferon responses that result in inflammation and autoimmune conditions. This could explain the skin manifestations associated with these vaccines. Allergenic components in the vaccines could also be a possible cause of these reactions. A patch test can be performed to prevent these reactions in susceptible individuals. CONCLUSIONS: This report highlights the need for vigilance to detect severe allergic reactions after covid 19 vaccination to improve the safety of the vaccine. Reference #1: WHO coronavirus (COVID-19) dashboard. [ Jul;2021 ];https://covid19.who.int/ 2021 DISCLOSURES: No relevant relationships by Ruhma Ali No relevant relationships by Sneha Bijoy No relevant relationships by Chrystina Kiwan no disclosure on file for Richard Miller;No relevant relationships by Aditya Patel No relevant relationships by jihad slim, value=Honoraria Removed 03/25/2022 by jihad slim No relevant relationships by jihad slim, value=Honoraria Removed 03/25/2022 by jihad slim No relevant relationships by jihad slim, value=Honoraria Removed 03/25/2022 by jihad slim No relevant relationships by jihad slim, value=Honoraria Removed 03/25/2022 by jihad slim No relevant relationships by jihad slim, value=Honoraria Removed 03/25/2022 by jihad slim

Pulse oximeter as a home assessment tool: Knowledge and user experience among the community in Malaysia during the COVID-19 pandemic

Objective: To determine the degree of knowledge in the usage of pulse oximeter as a home assessment tool among the community in Malaysia. Methods: A cross-sectional survey was conducted in November 2021. The questionnaire assessed the knowledge in using pulse oximeters, user experience and opinions in using pulse oximeter as a home assessment tool during the pandemic. Results: A total of 504 respondents were included in the study, and the mean score in knowledge related to application of pulse oximetry was 73.00%, while the mean score in knowledge related to factors affecting pulse oximetry readings was only 38.51%. A total of 90.5% of the respondents recognised normal pulse rate and 88.5% knew the blood oxygen saturation levels of a healthy adult, while 69.4% recognised the definition of silent hypoxia. In addition, the majority of the respondents agreed that factors such as poor blood circulation (71.2%), excessive movements (69.8%), and hand position (60.7%) affected oximetry readings. However, 61.7%, 81.7%, 77.2% and 76.8% of the respondents could not identify nail polish, skin colour, skin thickness and tattoos as factors that may affect oximetry readings respectively. Conclusions: The respondents showed a satisfactory level of knowledge related to application of pulse oximetry, but a poor level of knowledge related to factors affecting pulse oximetry readings among the community in Malaysia. Continuous efforts in educating the community on the correct use of pulse oximeters are crucial for appropriate home assessment and avoiding unnecessary stress.