Erythema multiforme related to AstraZeneca SARS-CoV-2 vaccine

ABSTRACT

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.