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Gupta D, Goldberg L, Dickinson A, Hughes M, Anand V, Stokke J, Corden MH. An 8-Year-Old Boy With Prolonged Fever and Subcutaneous Nodules. Pediatrics 2022; 149:186710. [PMID: 35490281 DOI: 10.1542/peds.2021-052974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2021] [Indexed: 11/24/2022] Open
Abstract
An 8-year-old boy with asthma presented with prolonged fever, malaise, extremity weakness, polyarthralgias, malar rash, and subcutaneous nodules. Physical examination was remarkable for a faint malar rash, flesh-colored papules on the dorsal aspect of the fingers, arthritis of multiple joints in the hands, and subcutaneous nodules. The nodules were firm, nontender, and distributed over multiple extremities and the trunk. The patient was admitted to expedite workup. Initial laboratory test results revealed leukopenia, mild elevation of the aminotransferases, an elevated erythrocyte sedimentation rate, and normal level of creatine kinase. His echocardiogram was normal. Infectious disease studies were negative. Additional examination revealed dilated capillaries in his nail beds and bilateral hip weakness. MRI of his extremities was negative for myositis or calcification of the nodules. We obtained a biopsy of the subcutaneous nodules, and because the patient remained afebrile during the hospitalization, we discharged him from the hospital with outpatient follow-up. Our expert panel reviews the course of the patient's evaluation and investigation, as well as the implications of his diagnosis based on the tissue pathology from the nodule biopsy.
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Affiliation(s)
| | | | | | - Meagan Hughes
- Dermatology.,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Vikram Anand
- Infectious Diseases.,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Jamie Stokke
- Cancer and Blood Disease Institute.,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Mark H Corden
- Hospital Medicine, Department of Pediatrics, Children's Hospital Los Angeles.,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
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Collinson AC, Moore L, Cheung A, Gold MS, Goh DW. Subcutaneous nodules following vaccination. J Paediatr Child Health 2022; 58:388-391. [PMID: 35137488 DOI: 10.1111/jpc.15900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 10/26/2021] [Accepted: 01/04/2022] [Indexed: 11/26/2022]
Abstract
Five patients presented to surgical clinics at our institution with subcutaneous nodules of the upper arm or thigh present for 6-18 months. Excisional or fine-needle biopsy was performed due to diagnostic uncertainty and parental concern. Histopathological examination revealed these to be cutaneous lymphoid hyperplasia in reaction to vaccine components. Nodular reactions with this histopathological pattern are well recognised within vaccine-related literature, but less commonly recognised in patients presenting to general paediatric or surgical clinics. This article reviews literature on delayed-onset nodule formation after vaccination and recommends observation and reassurance as mainstays of management of this largely benign entity.
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Affiliation(s)
- Anne C Collinson
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Lynette Moore
- Department of Anatomical Pathology, SA Pathology, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Abigail Cheung
- Department of Allergy and Clinical Immunology, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Michael S Gold
- Department of Allergy and Clinical Immunology, Women's and Children's Hospital, Adelaide, South Australia, Australia.,Discipline of Paediatrics, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Day Way Goh
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia.,Discipline of Paediatrics, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
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González Pérez AM, Nájera Botello L, Suarez Massa D, Roustan Gullón G, Alfageme Roldán F. Sonography of subcutaneous nodules following immunization with histopathological correlation: a three-case series. J Ultrasound 2021; 25:355-360. [PMID: 33400252 DOI: 10.1007/s40477-020-00554-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 12/13/2020] [Indexed: 11/26/2022] Open
Abstract
Subcutaneous nodules are a rare adverse event following immunization frequently associated with suboptimal injection procedures and aluminium-containing vaccines. We present three cases of subcutaneous nodules following immunization describing their clinical signs, histopathological features and ultrasound findings and demonstrating the use of sonography as an aid to the diagnosis of this entity.
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Affiliation(s)
- Ana María González Pérez
- Department of Dermatology, Hospital Clínico Universitario de Salamanca, Paseo de San Vicente 182, 37007, Salamanca, Spain
| | - Laura Nájera Botello
- Pathology Department, Hospital Universitario Puerta de Hierro Majadahonda, C/Manuel de Falla 2, 29022, Majadahonda, Madrid, Spain
| | - Dolores Suarez Massa
- Pathology Department, Hospital Universitario Puerta de Hierro Majadahonda, C/Manuel de Falla 2, 29022, Majadahonda, Madrid, Spain
| | - Gastón Roustan Gullón
- Department of Dermatology, Hospital Universitario Puerta de Hierro Majadahonda, C/Manuel de Falla 2, 29022, Majadahonda, Madrid, Spain
| | - Fernando Alfageme Roldán
- Department of Dermatology, Hospital Universitario Puerta de Hierro Majadahonda, C/Manuel de Falla 2, 29022, Majadahonda, Madrid, Spain.
- Department of Dermatology, Autonomous University of Madrid, Calle Joaquín Rodrigo, 1, 28222, Majadahonda, Madrid, Spain.
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Zanoni G, Migliorini M, Gallo T, Guidolin L, Schena D. Recurrent injection site reactions to vaccines: Two clinical patterns of presentation. Vaccine 2020; 38:6985-6989. [PMID: 32919826 DOI: 10.1016/j.vaccine.2020.08.073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/27/2020] [Accepted: 08/30/2020] [Indexed: 11/30/2022]
Abstract
After administration of injectable vaccines, skin manifestations are common and they usually disappear in a few hours or days. We describe a case series of recurrent injection site reactions in 8 children undergoing vaccines of the regional immunization schedule, which required specialized evaluation and advice for subsequent vaccinations. Two clinical patterns of reactions were observed. Four children manifested recurrent wheal and erythema with pruritus at vaccine injection site for up to 7 months; the remaining children showed an itching plaque or nodule at injection site, that lasted several months after vaccination with exacerbations of pruritus and erythema. Hypersensitivity to aluminium salts was demonstrated in the second group. The flare-up manifestations, related to Meningococcal B vaccine in 5 reactions, were triggered by concurrent viral infections in two patients. Communication of risks and diagnostic testing, when appropriate, resulted important to reassure parents of children and favour adequate completion of vaccination.
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Affiliation(s)
- Giovanna Zanoni
- Immunology Unit, University Hospital, Azienda Ospedaliera Universitaria Integrata Verona, Italy.
| | - Mariasole Migliorini
- Immunology Unit, University Hospital, Azienda Ospedaliera Universitaria Integrata Verona, Italy
| | - Tolinda Gallo
- Public Health Department, Udine Healthcare and University Integrated Trust, Udine, Italy
| | - Lucia Guidolin
- Immunology Unit, University Hospital, Azienda Ospedaliera Universitaria Integrata Verona, Italy
| | - Donatella Schena
- Dermatology Unit, Azienda Ospedaliera Universitaria Integrata Verona, Italy
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Abstract
Subcutaneous vaccine (SC) administration is an outmoded practice which complicates vaccine administration recommendations. Local adverse events following immunization (AEFIs) are a recognized determinant of vaccine hesitancy/refusal which can lead to an increased prevalence of vaccine-preventable disease. This extensive narrative review provides high-grade evidence that intramuscular (IM) administration of all vaccine types [adjuvanted, live virus and non-adjuvanted (inactivated whole cell, split cell and subunit)] significantly reduces the likelihood of local adverse events. This, combined with moderate grade evidence that IM injection generates significantly greater immune response compared with SC injection, allows a strong recommendation to be made for the IM injection of all vaccines except BCG and Rotavirus. This will simplify vaccination practice, minimize the inadvertent misadministration of vaccines and potentially improve public trust in vaccination.
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Affiliation(s)
- Ian F Cook
- Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
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Silcock R, Crawford NW, Selvaraj G, McMinn A, Danchin M, Lazzaro T, Perrett KP. Subcutaneous nodules following immunization in children; in Victoria, Australia from 2007 to 2016. Vaccine 2020; 38:3169-3177. [PMID: 32147295 DOI: 10.1016/j.vaccine.2019.12.066] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 11/29/2019] [Accepted: 12/31/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Subcutaneous nodules are a rare adverse event following immunization (AEFI). We aimed to describe nodules at the injection site reported to SAEFVIC (Surveillance of Adverse Events Following Vaccination in the Community) using the Brighton Collaboration Case Definition (BCCD), management and recurrence following subsequent immunizations. METHOD We assessed 58 cases (<18 years of age) of 'nodule at injection site' reported to SAEFVIC, Melbourne, Australia, between May 2007 and June 2016. Case details were analyzed from records and phone interview follow-up. The Australian Immunization Registry was reviewed for immunization status. RESULTS 71% (41/58 reported cases) were consistent with the BCCD for subcutaneous nodule, 14% (8 cases) were 'possible subcutaneous nodules', 10% (6 cases) were nodules associated with BCG immunization and 5% (3 cases) were attributable to an alternative diagnosis. The median age at immunization was 12 months, (range 1 month-12 years); 54% male (22/41 cases). 17% (7 cases) had multiple nodules. Nodules were associated with immunizations containing aluminum (74%, 36/49 nodules), no aluminum (8%, 4 nodules) and unknown (18%, 9 nodules). Most cases developed symptoms within 3 days post-immunization (59%, 24 cases) and in the thigh (59%, 29 nodules). Pruritus was associated in 41% (17 cases). Around 1/3 (34%) of nodules resolved 6 months post immunization, 2/3 (68%) by 12 months, however 1/4 (24%) remained persistent for >24 months. 5 cases had prior nodules and 1 case had recurrence with subsequent immunization. 83% (34 cases) were fully immunized for age at follow-up. CONCLUSION Subcutaneous nodules at the injection site may occur following a wide range of vaccines, including vaccines without aluminum. All cases require careful review and where possible, specialist management and to support subsequent immunizations.
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Affiliation(s)
- Rowena Silcock
- Department of General Medicine, Royal Children's Hospital, Melbourne, Australia; SAEFVIC (Surveillance of Adverse Events Following Vaccination in the Community), Murdoch Children's Research Institute, Melbourne, Australia.
| | - Nigel W Crawford
- Department of General Medicine, Royal Children's Hospital, Melbourne, Australia; SAEFVIC (Surveillance of Adverse Events Following Vaccination in the Community), Murdoch Children's Research Institute, Melbourne, Australia.
| | - Gowri Selvaraj
- SAEFVIC (Surveillance of Adverse Events Following Vaccination in the Community), Murdoch Children's Research Institute, Melbourne, Australia.
| | - Alissa McMinn
- SAEFVIC (Surveillance of Adverse Events Following Vaccination in the Community), Murdoch Children's Research Institute, Melbourne, Australia.
| | - Margie Danchin
- Department of General Medicine, Royal Children's Hospital, Melbourne, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Australia; Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia; Vaccine and Immunisation Research Group, Murdoch Children's Research Institute, Melbourne, Australia.
| | - Teresa Lazzaro
- Department of General Medicine, Royal Children's Hospital, Melbourne, Australia.
| | - Kirsten P Perrett
- Population Allergy Research Group and Melbourne Children's Trial Centre, Murdoch Children's Research Institute, Melbourne, Australia; Department of Allergy and Immunology and General Medicine, Royal Children's Hospital, Melbourne, Australia; Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia.
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