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Nahm WJ, Juarez M, Wu J, Kim RH. Eosinophil-rich linear IgA bullous dermatosis induced by mRNA COVID-19 booster vaccine. J Cutan Pathol 2023; 50:24-28. [PMID: 35922892 PMCID: PMC9538274 DOI: 10.1111/cup.14305] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/09/2022] [Accepted: 08/01/2022] [Indexed: 01/03/2023]
Abstract
We present a case of eosinophil-rich linear IgA bullous disease (LABD) following the administration of a messenger RNA COVID-19 booster vaccine. A 66-year-old man presented to the emergency department with a 3-week history of a pruritic blistering rash characterized by fluid-filled bullae and multiple annular and polycyclic plaques. He was initially diagnosed with bullous pemphigoid based on a biopsy showing a subepidermal blister with numerous eosinophils. However, direct immunofluorescence studies showed linear IgA and IgM deposition along the basement membrane zone with no immunoreactivity for C3 or IgG. Additionally, indirect immunofluorescence was positive for IgA basement membrane zone antibody. The patient was subsequently diagnosed with LABD and initiated on dapsone therapy with resolution of his lesions at 3-month follow-up. This case illustrates the growing number of autoimmune blistering adverse cutaneous reactions from vaccination. Dermatopathologists should be aware that features of autoimmune blistering diseases can overlap and may not be distinguishable based on these histopathological findings alone. Confirmation with direct immunofluorescence and/or serological studies may be necessary for accurate diagnosis.
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Affiliation(s)
- William J. Nahm
- The Ronald O. Perelman Department of DermatologyNYU Grossman School of MedicineNew YorkNew YorkUSA
| | - Michelle Juarez
- The Ronald O. Perelman Department of DermatologyNYU Grossman School of MedicineNew YorkNew YorkUSA
| | - Julie Wu
- The Ronald O. Perelman Department of DermatologyNYU Grossman School of MedicineNew YorkNew YorkUSA
| | - Randie H. Kim
- The Ronald O. Perelman Department of DermatologyNYU Grossman School of MedicineNew YorkNew YorkUSA
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2
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Deschaine MA, Lehman JS. The interface reaction pattern in the skin: an integrated review of clinical and pathological features. Hum Pathol 2019; 91:86-113. [DOI: 10.1016/j.humpath.2019.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 06/18/2019] [Accepted: 06/20/2019] [Indexed: 12/14/2022]
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Ruiz-Rivero J, Hernández-Aragüés I, Pulido-Pérez A, Suárez-Fernández R. Linear IgA Bullous Dermatosis Presenting as Toxic Epidermal Necrolysis. ACTAS DERMO-SIFILIOGRAFICAS 2017; 108:880-882. [PMID: 28751000 DOI: 10.1016/j.ad.2017.02.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 02/09/2017] [Accepted: 02/14/2017] [Indexed: 10/19/2022] Open
Affiliation(s)
- J Ruiz-Rivero
- Servicio de Dermatología y Venereología Médico-Quirúrgica, Hospital General Universitario Gregorio Marañón, Madrid, España.
| | - I Hernández-Aragüés
- Servicio de Dermatología y Venereología Médico-Quirúrgica, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - A Pulido-Pérez
- Servicio de Dermatología y Venereología Médico-Quirúrgica, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - R Suárez-Fernández
- Servicio de Dermatología y Venereología Médico-Quirúrgica, Hospital General Universitario Gregorio Marañón, Madrid, España
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Onodera H, Mihm MC, Yoshida A, Akasaka T. Drug-Induced Linear IgA Bullous Dermatosis. J Dermatol 2014; 32:759-64. [PMID: 16361722 DOI: 10.1111/j.1346-8138.2005.tb00839.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2005] [Accepted: 04/27/2005] [Indexed: 11/30/2022]
Abstract
We report the case of a 69-year-old Japanese woman with multiple blistering lesions covering almost her whole body. Linear IgA and C3 depositions were seen at the basement membrane zone on direct immunofluorescence (IF). Linear IgA bullous dermatosis (LABD) is one of the autoimmune diseases resulting in subepidermal blisters. It is clinically similar to bullous pemphigoid and IF is required to distinguish the two diseases. In this case, the blistering lesions appeared after vancomycin treatment. This drug was strongly suspected as a cause of LABD in light of the clinical course of the patient even though a drug-lymphocyte stimulating test was negative. Among the various implicated causative drugs, vancomycin is the most commonly associated with LABD.
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Affiliation(s)
- Hanae Onodera
- Dermatopathology Unit, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Warren 827, Boston, MA 02114, USA
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5
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Kakar R, Paugh H, Jaworsky C. Linear IgA bullous disease presenting as toxic epidermal necrolysis: a case report and review of the literature. Dermatology 2013; 227:209-13. [PMID: 24135381 DOI: 10.1159/000353584] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 06/10/2013] [Indexed: 11/19/2022] Open
Abstract
A 91-year-old female presented with widespread skin sloughing and bullae clinically mimicking toxic epidermal necrolysis (TEN). The patient was on multiple antibiotics, including vancomycin and piperacillin/tazobactam. Histopathology and direct immunofluorescence were consistent with a diagnosis of linear IgA bullous disease (LABD). In a PubMed review of the literature from 1975 to the present, there have been 15 cases of LABD presenting as TEN clinically and with characteristic linear IgA deposits on direct immunofluorescence studies. Vancomycin and phenytoin were the most commonly implicated medications. Twelve patients saw a resolution or healing of skin lesions after discontinuation of the implicated medication. There were, however, 5 patients who died of complications related to their comorbidities. It is important to include LABD in the differential diagnosis when evaluating patients who clinically present with TEN.
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Affiliation(s)
- Rohit Kakar
- Department of Dermatology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
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Hernández N, Borrego L, Soler E, Hernández J. Dermatosis ampollosa inducida por inmunoglobulina A lineal con clínica de síndrome DRESS por sulfasalazina. ACTAS DERMO-SIFILIOGRAFICAS 2013. [DOI: 10.1016/j.ad.2011.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Hernández N, Borrego L, Soler E, Hernández J. Sulfasalazine-induced linear immunoglobulin A bullous dermatosis with DRESS. ACTAS DERMO-SIFILIOGRAFICAS 2013; 104:343-6. [PMID: 23562401 DOI: 10.1016/j.adengl.2011.11.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Accepted: 11/13/2011] [Indexed: 10/27/2022] Open
Abstract
Linear immunoglobulin (Ig) A dermatosis is an immune-mediated bullous disease characterized by linear deposits of IgA along the basal membrane. While usually idiopathic, it can occasionally be induced by drug exposure. We report the case of a 60-year-old woman with rheumatoid arthritis being treated with sulfasalazine who developed linear IgA dermatosis and drug rash with eosinophilia and systemic symptoms (DRESS). The dermatosis and associated symptoms resolved following withdrawal of the drug and treatment with systemic corticosteroids for 2 months. This is the first report of sulfasalazine-induced linear IgA dermatosis in association with DRESS and we believe that sulfasalazine should be added to the list of drugs that can cause linear IgA dermatosis.
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Affiliation(s)
- N Hernández
- Servicio de Dermatología, Complejo Hospitalario Universitario Insular Materno Infantil de Gran Canaria, Las Palmas, Spain.
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Abstract
BACKGROUND Linear IgA bullous dermatosis (LABD) is an acquired autoimmune sub-epidermal vesiculobullous disease characterized by continuous linear IgA deposit on the basement membrane zone, as visualized on direct immunofluorescence microscopy. LABD can affect both adults and children. The disease is very uncommon, with a still unknown incidence in the South American population. MATERIALS AND METHODS All confirmed cases of LABD by histological and immunofluorescence in our hospital were studied. RESULTS The confirmed cases were three females and two males, aged from 8 to 87 years. Precipitant events associated with LABD were drug consumption (non-steroid inflammatory agents in two cases) and ulcerative colitis (one case). Most of our patients were treated with dapsone, resulting in remission. DISCUSSION Our series confirms the heterogeneous clinical features of this uncommon disease in concordance with a larger series of patients reported in the literature.
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Affiliation(s)
- Mauricio Sandoval
- Department of Dermatology, Pontificia Universidad Católica de Chile, Santiago, Chile.
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Fortuna G, Salas-Alanis JC, Guidetti E, Marinkovich MP. A critical reappraisal of the current data on drug-induced linear immunoglobulin A bullous dermatosis: A real and separate nosological entity? J Am Acad Dermatol 2012; 66:988-94. [DOI: 10.1016/j.jaad.2011.09.018] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Revised: 09/08/2011] [Accepted: 09/20/2011] [Indexed: 01/22/2023]
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[Verapamil-induced linear IgA disease mimicking toxic epidermal necrolysis]. Ann Dermatol Venereol 2011; 138:302-6. [PMID: 21497257 DOI: 10.1016/j.annder.2010.10.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2010] [Revised: 08/30/2010] [Accepted: 10/28/2010] [Indexed: 11/20/2022]
Abstract
BACKGROUND Linear IgA bullous dermatosis is a rare auto-immune bullous dermatitis characterized by linear IgA deposits in the basal membrane zone. Clinical diagnosis may be difficult due to the various clinical presentations mimicking bullous pemphigoid, pemphigus, erythema multiforme or toxic epidermal necrolysis. Linear IgA may be idiopathic or due to drugs, particularly vancomycin. PATIENTS AND METHODS We describe a 91-year-old woman treated with verapamil for coronary disease who developed an eruption presenting as a toxic epidermal necrolysis, although the diagnosis was amended after direct immunofluorescence revealed IgA deposits in the basal membrane zone. DISCUSSION Ours appears to be the first reported case of verapamil-induced linear IgA bullous dermatosis.
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Khan I, Hughes R, Curran S, Marren P. Drug-associated linear IgA disease mimicking toxic epidermal necrolysis. Clin Exp Dermatol 2009; 34:715-7. [DOI: 10.1111/j.1365-2230.2008.03011.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Kang MJ, Kim HO, Park YM. Vancomycin-induced Linear IgA Bullous Dermatosis: A Case Report and Review of the Literature. Ann Dermatol 2008; 20:102-6. [PMID: 27303171 DOI: 10.5021/ad.2008.20.2.102] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2006] [Accepted: 03/01/2008] [Indexed: 11/08/2022] Open
Abstract
Linear IgA bullous dermatosis (LABD) is a rare autoimmune bullous disease that can either occur without any apparent cause or be induced by the administration of certain drugs, the most common of which is vancomycin. We present a case of a 45-year-old woman who was diagnosed with vancomycin-induced LABD by the presence of a characteristic linear band of IgA along the basement membrane zone on direct immunofluorescence microscopy. Our patient showed complete recovery after a 2-week period during which vancomycin administration was discontinued.
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Affiliation(s)
- Min Ju Kang
- Department of Dermatology, The Catholic University of Korea, Kangnam St. Mary's Hospital, Seoul, Korea
| | - Hyung Ok Kim
- Department of Dermatology, The Catholic University of Korea, Kangnam St. Mary's Hospital, Seoul, Korea
| | - Young Min Park
- Department of Dermatology, The Catholic University of Korea, Kangnam St. Mary's Hospital, Seoul, Korea
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Coelho S, Tellechea O, Reis JP, Mariano A, Figueiredo A. Vancomycin-associated linear IgA bullous dermatosis mimicking toxic epidermal necrolysis. Int J Dermatol 2007; 45:995-6. [PMID: 16911399 DOI: 10.1111/j.1365-4632.2006.02752.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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14
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Ting W, Stone MS, Racila D, Scofield RH, Sontheimer RD. Toxic epidermal necrolysis-like acute cutaneous lupus erythematosus and the spectrum of the acute syndrome of apoptotic pan-epidermolysis (ASAP): a case report, concept review and proposal for new classification of lupus erythematosus vesiculobullous skin lesions. Lupus 2005; 13:941-50. [PMID: 15645750 DOI: 10.1191/0961203304lu2037sa] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The acute clinical syndrome of toxic epidermal necrolysis (TEN) is currently thought to be a distinct clinical-pathological entity typically resulting from drug hypersensitivity. We describe an adult woman who experienced a fulminate pattern of apoptotic epidermal cell injury following tanning bed exposure while taking naproxen that resulted in a clinical presentation having combined features of drug-induced TEN and an infrequently recognized form of bullous cutaneous lupus erythematosus (LE). This case calls attention to the fact that TEN-like injury can occasionally be seen in settings other than drug hypersensitivity (e.g., LE, acute graft versus host disease) and illustrates the need for a unifying concept in this area. We therefore propose the term 'Acute Syndrome of Apoptotic Pan-Epidermolysis (ASAP)' to designate a clinical syndrome that is characterized by life-threatening acute and massive cleavage of the epidermis resulting from hyperacute apoptotic injury of the epidermis. We also review vesiculobullous skin disorders that can be encountered in LE patients and suggest a new classification scheme for such lesions.
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Affiliation(s)
- W Ting
- Department of Dermatology, Camino Medical Group, Sunnyvale, CA, USA
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Abstract
Phenytoin (diphenylhydantoin; Dilantin), ALZA Corp.) is a highly effective and widely prescribed anticonvulsant agent used in the treatment of focal and tonic clonic generalised seizures. The side effects of phenytoin can occassionally engender significant morbidity. Phenytoin can induce generalised eruptions that include: a maculopapular exanthem, Stevens-Johnson syndrome, generalised exfoliative dermatitis, toxic epidermal necrolysis, vasculitis and fixed drug eruptions. Phenytoin is linked to a hypersensitivity syndrome that manifests with fever, rash and lymphadenopathy. Patients receiving phenytoin may develop pseudolymphoma or, rarely, malignant lymphoma and mycosis fungoides-like lesions. Rarer cutaneous side effects include drug-induced lupus, purple hand syndrome, pigmentary alterations and IgA bullous dermatosis. Phenytoin can effect clotting function and alter vitamin and mineral levels. Prenatal exposure to phenytoin may result in a spectrum of structural, developmental and behavioural changes, known as the fetal hydantoin syndrome. Patients who use phenytoin in the long-term commonly manifest with gingival hyperplasia, coarsening of the facies, and hirsutism.
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Affiliation(s)
- Noah Scheinfeld
- St. Lukes Roosevelt Hospital Center, Department of Dermatology, 1090 Amsterdam Avenue, Suite 11D, New York, NY 10025, USA.
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Burch J, Weston W. Serious drug rashes in children. Adv Pediatr 2005; 52:207-22. [PMID: 16124342 DOI: 10.1016/j.yapd.2005.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Joanna Burch
- University of Colorado School of Medicine, Denver, Colorado, USA
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Waldman MA, Black DR, Callen JP. Vancomycin-induced linear IgA bullous disease presenting as toxic epidermal necrolysis. Clin Exp Dermatol 2004; 29:633-6. [PMID: 15550142 DOI: 10.1111/j.1365-2230.2004.01649.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Linear IgA bullous dermatosis (LABD) is a rare autoimmune vesiculobullous disorder characterized by variable clinical presentations that may mimic bullous pemphigoid, dermatitis herpetiformis, cicatricial pemphigoid and erythema multiforme. A few cases of drug-induced LABD that clinically resembled toxic epidermal necrolysis (TEN) have been reported. A subset of patients with LABD have been found to be drug-induced; the most common drug being vancomycin. The diagnosis of LABD is confirmed by the presence of a linear band of IgA along the basement membrane zone on direct immunofluorescence microscopy. We report a case of a 77-year-old man who presented to us with vancomycin-induced LABD that presented clinically as TEN. He had a complete recovery over a 3-week period following discontinuation of the vancomycin and the addition of oral dapsone therapy. It is important to be aware that drug-induced LABD can mimic TEN.
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Affiliation(s)
- M A Waldman
- Division of Dermatology, Department of Medicine, University of Louisville School of Medicine, USA
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