ERYTHEMA NODOSUM-LIKE RASH AFTER SARS-COV-2 VACCINATION: A CASE REPORT

ABSTRACT

TOPIC Education, Research, and Quality Improvement TYPE Medical Student/Resident Case Reports INTRODUCTION: With the rapid emergence of SARS-CoV-2 and the pandemic implications carried forth, the medical community continues to improve vaccination efforts while monitoring potential side effects not initially considered. Erythema nodosum is known as a delayed-type hypersensitivity reaction with a pathophysiology not yet fully understood.1 Its classic presentation is diagnosed clinically by noting painful erythematous nodules on the bilateral lower extremities notably in the calves and shins. The condition is typically self-limiting. We present a case of erythema nodosum evoked by the SARS-CoV-2 Moderna vaccine. CASE PRESENTATION A 44-year-old Caucasian female with no significant past medical history presented to the emergency department (ED) at a community hospital with progressively worsening lower extremity rash. The rash started 7 days after the second administered dose of the SARS-CoV-2 vaccine (Moderna series). Prior to ED presentation, she had been seeing her primary care physician for her ongoing symptoms. Her vital signs in the emergency department were stable. Physical examination was benign other than multiple, tender, non-blanchable 6-8 cm erythematous nodules present on the bilateral calves and shins. Laboratory findings from her primary care physician's office noted negative ANA, rheumatoid factor, ESR, thyroid panel, upper respiratory viral panel including SARS-CoV-2, complete blood count, comprehensive metabolic profile, and coagulation PT-INR times. Her only notable finding was an elevated c-reactive protein of 23.5 mg/L. She was discharged from the ED and continued supportive care with nonsteroidal anti-inflammatory drugs. DISCUSSION: As SARS-CoV-2 vaccinations continue global administration, it becomes imperative to recognize and document noted adverse effects. This will allow education of potential side effects and lessen public fear from getting vaccinated. Cutaneous reactions are common enough to be noted from a variety of etiologies including infection, drugs, autoimmune processes and other disease and non-disease states. Specifically, erythema nodosum has been documented in the medical literature as sequela to SARS-CoV-2 infection.2 It has yet to be documented as a reaction to the vaccine. This presenting dermatologic pattern was of concern to the patient but should be recognizable to clinicians as self-limiting.3 Further citations of various presentations will continue to improve the characterization of the ongoing pandemic environment. CONCLUSIONS: As SARS-CoV-2 vaccination efforts continue on a global scale, it is important that both clinicians and patients have access to potential side effect manifestations and education. This will help reassure patients and the public in the safety of vaccine administration despite possible self-limiting cutaneous manifestations. It will also help improve navigation of the current healthcare landscape as more people get vaccinated. REFERENCE #1 Criado, Paulo Ricardo, et al. "Are the cutaneous manifestations during or due to SARS-CoV-2 infection/COVID-19 frequent or not? Revision of possible pathophysiologic mechanisms." Inflammation Research 69 (2020) 745-756. https//link.springer.com/content/pdf/10.1007/s00011-020-01370-w.pdf REFERENCE #2 Galvan Casas C, Catala A, Carretero Hernandez G, et al. Classification of the cutaneous manifestations of COVID-19 a rapid prospective nationwide consensus study in Spain with 375 cases [published online ahead of print, 2020 Apr 29]. Br J Dermatol. 2020;https//doi.org/10.1111/bjd.19163. REFERENCE #3 Inamadar AC, Adya KA. The rash with painful and erythematous nodules. Clin Dermatol. 2019 Mar-Apr;37(2)129-135. doi 10.1016/j.clindermatol.2018.12.006. Epub 2018 Dec 5. PMID 30981293. DISCLOSURES No relevant relationships by Martin Herrera, source=Web Response No relevant relationships by Heather Holstein, source=Web Response No relevant relationships by Kathryn West, source=Web Response