Urticaria after breakthrough Omicron BA.5.1 severe acute respiratory syndrome coronavirus 2 infection in a triple-vaccinated (Pfizer) patient: a case report.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 continues to threaten public health. The virus is causing breakthrough infections in vaccinated individuals. Also, scarce information is available about cutaneous manifestations after severe acute respiratory syndrome coronavirus 2 infection. CASE PRESENTATION AND FINDINGS: A case of a triple-vaccinated (Pfizer) 37-year-old Hispanic American (Colombian) male who developed urticaria after Omicron BA.5.1 severe acute respiratory syndrome coronavirus 2 breakthrough infection is described. Virus isolation and whole genome sequencing along with immune and molecular assays were performed. Dermatological manifestations (skin rash and urticaria) after Omicron BA.5.1 infection were observed. Sequence analysis of the Omicron BA.5.1 isolate also revealed several important mutations. Hemogram analysis revealed leukocytosis and neutrophilia. Serology testing revealed anti-spike immunoglobulin G serum titers but negative detection of immunoglobulin M at 10 days after symptom onset. Anti-nucleocapsid, anti-spike 1 immunoglobulin G, anti-spike trimer, and anti-receptor-binding-domain immunoglobulin G and immunoglobulin E sera were detected at different titers 10 days after symptom onset. Several serum levels of chemokines/cytokines (Interferon-α, interferon-γ, interleukin-12/interleukin-23p40, interleukin-18, interferon gamma-induced protein-10, monocyte chemoattractant protein-1, monokine induced by gamma, macrophage inflammatory protein-1α, chemokine (C-C motif) ligand-5 , tumor necrosis factor-ß1, Tumor necrosis factor-α) were detected, but interleukin-2, interleukin-4, interleukin-6, interleukin-8, and interleukin-17A were below the limit of detection. INTERPRETATION AND CONCLUSIONS: To our knowledge, this is the first study describing skin effects of a severe acute respiratory syndrome coronavirus 2 Omicron BA.5 variant breakthrough infection in a triple-vaccinated patient in Colombia. Several important mutations were found in the spike glycoprotein of the virus isolated; these mutations are associated with immune evasion and changes in antigenic properties of the virus. Physicians overseeing coronavirus disease 2019 cases should be aware of the potential skin effects of the infection. Pathogenesis of severe acute respiratory syndrome coronavirus 2 infection and its association with proinflammatory cytokines and chemokines may enhance the development of urticaria and other skin manifestations in immunized individuals. However, further studies are needed to better understand the complexity of coronavirus disease in such situations.

Cutaneous manifestations of Coronavirus Disease 2019.

BACKGROUND: COVID-19 has been linked to a variety of dermatological conditions. OBJECTIVE: To determine the presence of various cutaneous manifestations in patients with COVID-19, also to define their features in relation to the systemic symptoms. METHODS: This research enrolled a total of 1206 lab-confirmed COVID-19 individuals at a tertiary-care hospital in Karachi, Pakistan. Expert dermatologists assessed patients for COVID-related skin conditions. COVID-19 severity was categorized as asymptomatic/mild, moderate, or severe. RESULTS: Of the 102 (85.7%) patients with only one cutaneous sign, 26.5% developed maculopapular/morbiliform/erythematous rash; 14.7% urticaria; 9.85% vesicular/pustular exanthem; 14.7% vascular pattern; 12.7% infections, 7.8% miscellaneous and 9.8% late cutaneous findings A longer-lasting vascular pattern was related with an older age and a fatal COVID-19 outcomes (P: 0.000) compared with mild/moderate disease. Most of the retiform purpura presented exclusively with thromboembolic episodes. The moderate severity was correlated with maculopapular/morbiliform/exanthematous phenotype (P: 0.009), whereas urticaria was attributed to asymptomatic/mild disease (0.001) compared with moderate/severe infection. LIMITATIONS: Single-Center and observational study. CONCLUSION: Vascular lesions were correlated with disastrous COVID-19 outcomes, whereas retiform purpura was linked to adverse outcomes. The maculopapular/morbiliform/erythematous rash was associated with moderate severity, while the urticarial rash was linked to milder course compared with moderate/severe severity infection.

Hypocomplementemic urticarial vasculitis case with hemophagocytic lymphohistiocytosis following SARS-CoV-2 mRNA vaccination.

A 61-year-old man with no previous record of autoimmune disease developed fever, polyarthralgia, purpura, and urticaria-like rash 2 weeks after the first dose of the Moderna mRNA-1273 vaccine, and symptoms deteriorated following the second dose. He presented reduced erythrocyte and platelet counts, hyperferritinemia, high sIL-2R levels, and severe hypocomplementemia. We diagnosed hypocomplementemic urticarial vasculitis (HUVS), and his symptoms as well as laboratory findings improved following treatment with mPSL 1000 mg/day for 3 days and PSL 40 mg/day. Twelve weeks following treatment initiation, the patient relapsed with fever, sore throat, pancytopenia, and hyperferritinemia when the PSL dose was reduced to 12.5 mg/day. Bone marrow biopsy and MRI presented fatty marrow and hemophagocytosis. The patient's blood cells started recovering using ATG + CsA + EPAG therapy for hemophagocytic lymphohistiocytosis (HLH). This is the first case report of HUVS and HLH following SARS-CoV-2 mRNA vaccination. It is presumed that SARS-CoV-2 mRNA vaccine can induce the excessive production of certain types of cytokines, such as TNF-α, IL-1, IL-4, IL-5, IL-6, and IL-17 as a consequence of IL-6 Amplification (IL-6 Amp). SARS-CoV-2 mRNA-vaccines can cause disruption of immune homeostasis in healthy individuals. An extremely rare disease of HUVS complicated by HLH can be developed as a consequence.

Urticaria relapse after mRNA COVID-19 vaccines in patients affected by chronic spontaneous urticaria and treated with antihistamines plus omalizumab: A single-center experience.

Urticaria is a disease characterized by wheals and/or angioedema. Chronic spontaneous urticaria (CSU) occurs for longer than 6 weeks and appears independently of any identifiable exogenous stimulus. During the vaccination campaign for Coronavirus disease 2019 (COVID-19) pandemic, several cutaneous adverse events have been described, among which urticaria lasting less than 6 weeks (acute urticaria, AU). AU due to vaccines can be IgE or non-IgE mediated; the former typically develop within 4 h of drug exposure, the latter occurs later and the mechanism is unclear. In this retrospective study we analyzed the frequency and clinical characteristics of urticaria occurring after COVID-19 vaccine (post-vaccination urticaria relapse) in adult CSU patients treated with antihistamine and omalizumab, and in clinical remission.

Acute urticaria alone after CoronaVac COVID-19 vaccination should not be a contraindication for revaccination.

Patients who develop an immediate allergic reaction within the first 4 h of COVID-19 vaccine injection are recommended not to receive the same vaccine again. This recommendation mainly focuses on the mRNA and adenoviral vector COVID-19 vaccines, but data for whole virus vaccines are unknown. We report seven patients who developed an immediate reaction within 4 h (six had generalized urticaria, one had localized urticaria) after the first vaccination with CoronaVac, the inactivated SARS-CoV-2 vaccine. The results of skin tests and basophil activation tests suggested that spike peptides play a role in exacerbating urticaria in some patients. However, all subjects who developed urticaria within 4 h after CoronaVac vaccination were successfully revaccinated without graded challenge, although recurrent urticaria was common. This preliminary result indicates that acute urticaria alone should not be a contraindication for the second dose of CoronaVac if the supply of alternative vaccines is limited.

[Urticaria associated with COVID-19 in allergic patients. A case series]. / Urticaria asociada a COVID-19 en pacientes alérgicos. Serie de casos.

INTRODUCTION: In December 2019, a new coronavirus was identified as the causal agent of the 2019 coronavirus disease (COVID-19) with a wide clinical spectrum that goes from asymptomatic cases to critical and fatal cases. Its usual manifestations are fever, cough, and fatigue; although some cases present skin lesions. CASES REPORT: The first case was a 30-year-old woman with a history of controlled solar urticaria who presented erythematous and pruritic wheals in malar and cervical regions and extremities; associated with general malaise, headaches, and nausea, in whom the presence of COVID-19 was confirmed; her condition improved with a quadruple dose of antihistamines. The second case was a 47-year-old woman with a history of wasp sting anaphylaxis, without mastocytosis, who presented nasal congestion, headaches, and hypogeusia associated with generalized, erythematous, and pruritic wheals, with confirmation of COVID-19; her condition improved with quadruple doses of antihistamines. CONCLUSIONS: Cutaneous manifestations associated with COVID-19 are frequent and can be classified as inflammatory and vascular. Among them, urticarial lesions occupy the fourth place, and although there could be some predominance of these in patients with a history of allergies, more studies are required to define an association.

Introducción: En diciembre de 2019 fue identificado un nuevo coronavirus como agente causal de la enfermedad por coronavirus del 2019 con un amplio espectro clínico, desde casos asintomáticos hasta críticos y fatales. Generalmente se manifiesta con fiebre, tos y fatiga, aunque algunos casos se presentan con lesiones cutáneas. Reporte de casos: El primer caso es una mujer de 30 años con antecedente de urticaria solar controlada quien presentó habones eritematosos y pruriginosos en región malar, cervical y extremidades, asociado a malestar general, cefalea y náuseas, en quien se confirmó la presencia de COVID-19, y mejoró con antihistamínicos a dosis cuádruple. El segundo caso es una mujer de 47 años con antecedente de anafilaxia por picadura de avispa, sin mastocitosis, quien presentó congestión nasal, cefalea e hipogeusia asociado a habones generalizados, eritematosos y pruriginosos, con confirmación de COVID-19, y mejoría con dosis cuadruple de antihistamínicos. Conclusiones: Las manifestaciones cutáneas asociadas a COVID-19 son frecuentes y se pueden clasificar en inflamatorias y vasculares. Dentro de ellas, las lesiones urticariales ocupan el cuarto lugar, y aunque podría existir algún predominio de estas en pacientes con antecedentes de alergias, se necesitan más estudios para definir una asociación.

BASCULE syndrome in a child with prior asymptomatic COVID-19 infection.

BASCULE syndrome, characterized by Bier anemic spots, cyanosis, and an urticaria-like eruption, has been described as a benign vasomotor dermatosis that occurs in the setting of transient tissue hypoxia. It has been postulated that dermal ischemia triggers an exaggerated vasoconstrictive arteriolar reaction, which then causes a paradoxical urticarial rash by an unknown mechanism. In patients with COVID-19, there is evidence of angiocentric inflammation leading to vasoconstriction, endothelial damage, and thrombosis. We present a case of acute-onset BASCULE syndrome appearing after asymptomatic infection with COVID-19. BASCULE syndrome should be considered in the expanding spectrum of dermatologic manifestations associated with COVID-19.

[Cutaneous manifestations in patients with COVID-19 with significant attention to urticaria]. / Manifestaciones cutáneas en los pacientes con COVID-19 con especial atención en la urticaria.

OBJECTIVES: To describe the most frequent dermatological conditions observed in COVID-19 patients and to determine whether their presence could be used to establish an early diagnosis or to predict the progression of the infection. METHODS: There was a review in PubMed/MEDLINE and EMBASE of all the articles that had been published between January 1st and November 1st, 2020, with the search terms focused on "SARS-CoV-2", "COVID-19" and "Skin diseases". RESULTS: Eighty three studies met the inclusion criteria. Skin lesions have been reported in 0.2 % of the patients. The most frequently reported dermatoses were: maculopapular/ morbilliform rashes, urticaria and angioedema, chilblain-like acral pattern, and vesicular lesions. Among researchers, there are differences of opinion about a possible diagnostic or prognostic value of the skin diseases that are associated to the infection. CONCLUSIONS: It is advisable to consider the diagnosis of SARS-CoV-2 infection in patients who call the doctor for skin lesions, urticaria, or angioedema, with or without other symptoms of the infection, especially if there is a previous history of recent exposure to other infected subjects.

Objetivos: Describir las afecciones dermatológicas más frecuentes en los pacientes con la COVID-19 y precisar si su presencia puede ser utilizada para establecer un diagnóstico temprano o para predecir la evolución de la infección. Métodos: Se realizó una revisión en PubMed/MEDLINE y EMBASE de todos los artículos publicados entre enero 1 y noviembre 1 de 2020, con los términos de la búsqueda centrados en "SARS-CoV-2", "COVID-19" y "Enfermedades cutáneas". Resultados: Cumplieron los criterios de inclusión 83 estudios. Lesiones de la piel han sido reportadas en 0.2 % de los pacientes. Las erupciones maculopapulares/morbiliformes, la urticaria y el angioedema, el patrón acral parecido a sabañones y las lesiones vesiculares fueron las dermatosis más frecuentemente informadas. Existen diferencias de opinión entre los investigadores, acerca de un posible valor diagnóstico o pronóstico de las afecciones cutáneas asociadas con la infección. Conclusiones: Es recomendable considerar el diagnóstico de la infección por SARS-CoV-2 en pacientes que consultan por presentar lesiones cutáneas, urticaria o angioedema con o sin otros síntomas de la infección y en especial si existe algún antecedente de exposición reciente a otros sujetos infectados.

Cutaneous Manifestations of COVID-19 in the Inpatient Setting.

Cutaneous findings have increasingly been reported in patients with coronavirus disease 2019 (COVID-19). This review discusses associated skin findings in patients with COVID-19 in the inpatient setting, ranging from vasculopathy-related lesions associated with high hospitalization rate and poor prognosis to inflammatory vesicular and urticarial eruptions that are rarely associated with prolonged hospitalization. We also discuss other reported COVID-19 cutaneous manifestations such as Sweet's syndrome, purpuric eruptions, and Multisystem Inflammatory Syndrome in Children. Although the relationship between dermatologic changes and COVID-19 disease progression is not fully elucidated, familiarity with cutaneous manifestations is valuable for physicians caring for patients hospitalized with COVID-19 and may help improve disease recognition and care.

Cutaneous Manifestations of COVID-19: Characteristics, Pathogenesis, and the Role of Dermatology in the Pandemic.

Cutaneous manifestations of COVID-19-SARS-CoV-2-are common and varied. Morbilliform, vesicular, and urticarial eruptions may be nonspecific initial features of the disease. Chilblainlike lesions on the fingers or toes typically occur as part of a resolution phase, signifying a milder course, whereas livedoid lesions and retiform purpura are associated with coaguloapthy and more severe disease. Additionally, a severe Kawasaki-like multisystem inflammatory syndrome rarely is seen in children. This diverse range of cutaneous manifestations in COVID-19 reflects a spectrum of host immunologic responses to SARS-CoV-2 and may inform disease pathophysiology.