Exacerbation of subacute cutaneous lupus erythematosus following vaccination with BNT162b2 mRNA vaccine

Cutaneous manifestations of COVID-19 and COVID-19 vaccination

In December 2019, a new infectious pathogen named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was identified in Wuhan, China. Transmitted through respiratory droplets, SARS-CoV-2 is the causative pathogen of coronavirus disease 2019 (COVID-19). Although this new COVID-19 infection is known to cause primarily interstitial pneumonia and respiratory failure, it is often associated with cutaneous manifestations as well. These manifestations with COVID-19 can be classified into seven categories: (i) chilblain-like skin eruption (e.g., COVID toes), (ii) urticaria-like skin eruption, (iii) maculopapular lesions, (iv) vesicular eruptions, (v) purpura, (vi) livedo reticularis and necrotic lesions, (vii) urticarial vasculitis, and others such as alopecia and herpes zoster. The pathogenesis of skin eruptions can be broadly divided into vasculitic and inflammatory skin eruptions. Various cutaneous adverse reactions have also been observed after COVID-19 mRNA vaccination. The major cutaneous adverse reactions are type I hypersensitivity (urticaria and anaphylaxis) and type IV hypersensitivity (COVID arm and erythema multiform). Autoimmune-mediated reactions including bullous pemphigus, vasculitis, vitiligo, and alopecia areata have also been reported. Several cases with chilblain-like lesions and herpes zoster after COVID-19 mRNA vaccination have been published. Various skin diseases associated with COVID-19 and COVID-19 vaccination have been reported, and the mechanism has been partly elucidated. In the process, for example, some papers have reported that it is not related to COVID-19 infection, although it was initially called COVID-toe and considered a COVID-19-associated cutaneous eruption. In fact, some COVID-19-associated skin reactions are indistinguishable from drug eruptions. In the future, the mechanisms of COVID-19- or COVID-19 vaccine-associated skin reactions need to be elucidated and verification of causal relationships is required.

Vaccines and Autoimmunity-From Side Effects to ASIA Syndrome

Since vaccines are in fact manufactured chemical compounds such as drugs, the appearance of side effects following their use is not surprising. Similarly, as the main goal of vaccines is to stimulate the immune system bringing out the production of protective antibodies, autoimmune-related side effects as a consequence of increased immune activity do not seem irrational. Fortunately, the rate of such side effects is low; however, the importance of reporting adverse events following vaccinations, understanding the mechanisms behind their appearance, making early diagnosis, and appropriate treatment cannot be overemphasized. In fact, autoimmune-related side effects of vaccines, particularly those based on adjuvants, were reported long before the introduction of the autoimmune/inflammatory syndrome induced by adjuvants (ASIA). Nevertheless, ASIA gathered and united the side effects of vaccines under one title, a step which helped organize the research and call for better immune stimulators than adjuvants. New technologies and methods of making vaccines were clearly noticed during the pandemic of COVID-19 after the introduction of mRNA-based vaccines. In our current paper, we introduce the notion of side effects to vaccines, particularly those of autoimmune nature, the mechanisms of ASIA, and the main vaccines linked with the syndrome including the recent COVID-19 vaccines. The transition from side effects to ASIA is the main idea behind our work.

Various aspects of the relationship between vitiligo and the COVID-19 pandemic or SARS-CoV-2 vaccines: Clinical pearls for dermatologists

BACKGROUND

Coronavirus disease 2019 (COVID-19) has given rise to several new onset or exacerbated dermatologic disorders including vitiligo.

AIM AND METHOD

Here, we present different aspects of relationship between SARS-CoV-2 infection or its associated vaccines and vitiligo and aim to provide solutions to overcome the potential challenges.

RESULTS AND CONCLUSION

In brief, as the benefits overweigh the risks and since vaccine-triggered de novo or flares of vitiligo are uncommon and benign, these patients are recommended to get SARS-CoV-2 vaccines. Moreover, in individuals with previously recognized vitiligo, who are at risk of developing SARS-CoV-2 infection or those who are currently infected, special dermatologic consultation is needed in order to balance the immunosuppressive agents in their therapeutic regimen to prevent COVID-related morbidity and mortality.

X-linked Charcot-Marie-Tooth disease after SARS-CoV-2 vaccination mimicked stroke-like episodes: A case report

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccinations have been administered worldwide, with occasional reports of associated neurological complications. Specifically, the impact of vaccinations on individuals with X-linked Charcot-Marie-Tooth disease type 1 (CMTX1) is unclear. Patients with CMTX1 can have stroke-like episodes with posterior reversible encephalopathy syndrome on magnetic resonance imaging (MRI), although this is rare.

CASE SUMMARY

A 39-year-old man was admitted with episodic aphasia and dysphagia for 2 d. He received SARS-CoV-2 vaccination 39 d before admission. Physical examination showed pes cavus and reduced tendon reflexes. Brain MRI showed bilateral, symmetrical, restricted diffusion with T2 hyperintensities in the cerebral hemispheres. Nerve conduction studies revealed peripheral nerve damage. He was diagnosed with Charcot-Marie-Tooth disease, and a hemizygous mutation in the GJB1 gene on the X chromosome, known to be pathogenic for CMTX1, was identified. Initially, we suspected transient ischemic attack or demyelinating leukoencephalopathy. We initiated treatment with antithrombotic therapy and immunotherapy. At 1.5 mo after discharge, brain MRI showed complete resolution of lesions, with no recurrence.

CONCLUSION

SARS-CoV-2 vaccination could be a predisposing factor for CMTX1 and trigger a sudden presentation.

Presentation of SLE after COVID vaccination in a pediatric patient

BACKGROUND

The outbreak of severe acute respiratory syndrome coronavirus 2 has had an enormous impact on global health. Vaccination remains one of the most effective interventions for disease prevention. Clinically significant vaccine side effects are uncommon, though autoimmune-mediated disease occurs in a small percentage of vaccine recipients. Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease that is associated with significant morbidity and mortality. Childhood-onset SLE tends to have more severe disease manifestations than adult-onset SLE. In adults, there are a few reported cases of SLE developing soon after coronavirus disease 2019 (COVID-19) mRNA vaccination.

CASE PRESENTATION

A 14-year-old previously healthy male developed laboratory and clinical evidence of SLE, including maculopapular malar rash, arthritis, pleuritic chest pain, and class V (membranous) lupus nephritis, 2 days after his third dose of the Pfizer-BioNTech COVID-19 vaccine. The patient's symptoms improved after initiation of prednisone and mycophenolate mofetil. We also summarize eleven prior case reports describing SLE after COVID-19 vaccine in adults.

CONCLUSION

To our knowledge, this is the first reported pediatric patient with new onset SLE following COVID-19 mRNA vaccination. While potential mechanistic links exist between COVID-19 vaccination and SLE development, additional studies are necessary to elucidate the exact nature of this relationship.

SARS-CoV-2 Infection and Vaccination Cutaneous Manifestations for the Inpatient Dermatologist

Purpose of Review

The overall purpose of this review was to characterize and summarize cutaneous eruptions associated with coronavirus disease 2019 (COVID-19) as well as COVID-19 vaccination.

Recent Findings

Cutaneous eruptions associated with COVID-19 infection have a reported frequency of 1-20%. Increased COVID-19 disease severity has been associated with morbilliform exanthems, urticaria, retiform purpura, and livedo racemosa. Papulovesicular eruptions were associated with a milder COVID-19 disease course. A range of dermatoses have also been reported with COVID-19 vaccination but have rarely prevented subsequent vaccination.

Summary

Dermatologists should be aware of the associations between COVID-19 disease severity and cutaneous eruptions. Livedo racemosa and retiform purpura are particularly associated with increased disease severity and death. In the setting of COVID-19 vaccination, cutaneous eruptions can largely be managed symptomatically and very rarely do these reactions prevent subsequent vaccination.

Autoimmune and autoinflammatory conditions after COVID-19 vaccination. New case reports and updated literature review

Autoimmunity linked to COVID-19 immunization has been recorded throughout the pandemic. Herein we present six new patients who experienced relapses of previous autoimmune disease (AD) or developed a new autoimmune or autoinflammatory condition following vaccination. In addition, we documented additional cases through a systematic review of the literature up to August 1st, 2022, in which 464 studies (928 cases) were included. The majority of patients (53.6%) were women, with a median age of 48 years (IQR: 34 to 66). The median period between immunization and the start of symptoms was eight days (IQR: 3 to 14). New-onset conditions were observed in 81.5% (n: 756) of the cases. The most common diseases associated with new-onset events following vaccination were immune thrombocytopenia, myocarditis, and Guillain-Barré syndrome. In contrast, immune thrombocytopenia, psoriasis, IgA nephropathy, and systemic lupus erythematosus were the most common illnesses associated with relapsing episodes (18.5%, n: 172). The first dosage was linked with new-onset events (69.8% vs. 59.3%, P = 0.0100), whereas the second dose was related to relapsing disease (29.5% vs. 59.3%, P = 0.0159). New-onset conditions and relapsing diseases were more common in women (51.5% and 62.9%, respectively; P = 0.0081). The groups were evenly balanced in age. No deaths were recorded after the disease relapsed, while 4.7% of patients with new-onset conditions died (P = 0.0013). In conclusion, there may be an association between COVID-19 vaccination and autoimmune and inflammatory diseases. Some ADs seem to be more common than others. Vaccines and SARS-CoV-2 may induce autoimmunity through similar mechanisms. Large, well-controlled studies are warranted to validate this relationship and assess additional variables such as genetic and other environmental factors.

Global prevalence and clinical manifestations of cutaneous adverse reactions following COVID-19 vaccination: A systematic review and meta-analysis

Although vaccination is widely accepted as an effective method of preventing and controlling the COVID-19 pandemic, many people are concerned about possible cutaneous side effects which can delay or prevent them from being vaccinated. The objectives of this systematic review were to assess the global prevalence and clinical manifestations of cutaneous adverse reactions following COVID-19 vaccination. PubMed and Scopus databases were searched for articles published from January 1, 2019, to December 31, 2021, and reference lists for each selected article were screened. Case reports, case series, observational studies, and randomized controlled trials that provided information on cutaneous adverse reactions following COVID-19 vaccines were included. A total of 300 studies were included in a systematic review of which 32 studies with 946,366 participants were included in the meta-analysis. The pooled prevalence of cutaneous manifestations following COVID-19 vaccination was 3.8% (95% CI, 2.7%-5.3%). COVID-19 vaccines based on the mRNA platform had a higher prevalence than other platforms at 6.9% (95% CI, 3.8%-12.3%). Various cutaneous manifestations have been reported from injection site reactions which were the most common (72.16%) to uncommon adverse reactions such as delayed inflammatory reactions to tissue filler (0.07%) and flares of pre-existing dermatoses (0.07%). Severe cutaneous reactions such as anaphylaxis have also been reported, but in rare cases (0.05%). In conclusion, cutaneous adverse reactions are common, especially in those receiving mRNA vaccines. Most reactions are mild and are not contraindications to subsequent vaccination except for anaphylaxis, which rarely occurs. COVID-19 vaccination may also be associated with flares of pre-existing dermatoses and delayed inflammatory reactions to tissue filler. Patients with a history of allergies, pre-existing skin conditions, or scheduled for filler injections should receive additional pre-counseling and monitoring. A better understanding of potential side effects may strengthen public confidence in those wary of new vaccine technologies.

Case Report: Rowell Syndrome–Like Flare of Cutaneous Lupus Erythematosus Following COVID-19 Infection

The current COVID-19 pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has had an important impact on dermatology practice, posing diagnostic and therapeutic challenges especially in patients with inflammatory and autoimmune skin disorders. Disease-specific and nonspecific cutaneous manifestations have been increasingly reported in the spectrum of COVID-19 but the influence of the infection on pre-existing dermatologic diseases has not been clearly defined. There has been a debate in the literature as to whether patients suffering from autoimmune dermatoses, including cutaneous lupus erythematosus (CLE), are at increased risk of SARS-CoV-2 infection, as well as if they experience worsening of their lupus erythematosus (LE)-related clinical symptoms. This article reports on a case of Rowell syndrome occurring after COVID-19 in a 67-year old woman with pre-existing chronic CLE manifesting with few discoid lesions on the face, scalp, and upper chest, successfully controlled with topical corticosteroids and photoprotection. Erythema multiforme (EM)-like eruption developed approximately two weeks after the SARS-CoV-2 infection, the latter being confirmed by positive nasopharyngeal swab and successfully treated with systemic antibiotics and antiaggregants. Diffuse hair loss and patches of cicatricial alopecia were also present upon scalp examination. Laboratory workup, including routine tests, histologic, immunofluorescent, and serologic investigations, was supportive to the diagnosis. Administration of topical and systemic corticosteroids along with peroral hydroxychloroquine resulted in the progressive improvement of the cutaneous lesions. Rowell syndrome is a rare entity in the spectrum of LE, characterized by EM-like lesions, photosensitivity, and positive antinuclear and anti-Ro antibodies, that is currently considered to be a variant of subacute CLE (SCLE). Several cases of SCLE have been described in association with medications, including anti-SARS-CoV-2 vaccines but only a few reports incriminate the infection itself as a potential exacerbating factor. Based on the clinical course of the disease, we suggest that the observed Rowell syndrome-like flare of CLE was related to the COVID-19 infection in this patient.

New-Onset Systemic Lupus Erythematosus after mRNA SARS-CoV-2 Vaccination

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease resulting from the interaction of genetic and environmental factors. In addition, some antiviral vaccines have been associated with the onset of SLE. Few cases of SLE occurring after SARS-CoV-2 mRNA have been reported. Herein, we report the case of a 27-year-old woman with type I diabetes mellitus and family history of SLE who presented with symmetric inflammatory polyarthritis of the proximal interphalangeal joints, metacarpophalangeal joints, wrists, knees, and ankles two weeks after receiving the second dose of the SARS-CoV-2 mRNA-1273 vaccine. Laboratory results revealed positive antinuclear, anti-dsDNA, anti-Ro, and anti-La/SSB antibodies and low C4 levels. She was initially treated with low-dose prednisone and hydroxychloroquine. Hydroxychloroquine was discontinued after she developed an urticarial rash. Subsequently, mycophenolate mofetil was added after she developed proteinuria. This case highlights the importance of considering the diagnosis of SLE in patients who present with inflammatory polyarthritis after COVID-19 vaccination.

SARS-CoV-2 vaccine-related cutaneous manifestations: a systematic review

To date, over 250 million people have been reportedly infected by COVID‐19 disease, which has spread across the globe and led to approximately 5.1 million fatalities. To prevent both COVID‐19 and viral transmission, DNA‐based/RNA‐based vaccines, non‐replicating viral vector vaccines, and inactivated vaccines have been recently developed. However, a precise clinical and histological characterization of SARS‐CoV‐2 vaccine‐related dermatological manifestations is still lacking. A systematic review of 229 articles was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines, in order to provide an extensive overview of SARS‐CoV‐2 vaccine‐related skin manifestations. Data on demographics, number of reported cases with cutaneous involvement, vaccine, and rash type (morphology) were extracted from articles and summarized. A total of 5941 SARS‐CoV‐2 vaccine‐related dermatological manifestations were gathered. Local injection‐site reactions were the most frequently observed, followed by rash/unspecified cutaneous eruption, urticarial rashes, angioedema, herpes zoster, morbilliform/maculopapular/erythematous macular eruption, pityriasis rosea and pityriasis rosea‐like eruptions, and other less common dermatological manifestations. Flares of pre‐existing dermatological conditions were also reported. Cutaneous adverse reactions following SARS‐CoV‐2 vaccine administration seem to be heterogeneous, rather infrequent, and not life‐threatening. Vaccinated patients should be monitored for skin manifestations, and dermatological evaluation should be offered, when needed.

Guidelines on COVID-19 vaccination in patients with immune-mediated rheumatic diseases: a Brazilian Society of Rheumatology task force

OBJECTIVE

To provide guidelines on the coronavirus disease 2019 (COVID-19) vaccination in patients with immune-mediated rheumatic diseases (IMRD) to rheumatologists considering specific scenarios of the daily practice based on the shared-making decision (SMD) process.

METHODS

A task force was constituted by 24 rheumatologists (panel members), with clinical and research expertise in immunizations and infectious diseases in immunocompromised patients, endorsed by the Brazilian Society of Rheumatology (BSR), to develop guidelines for COVID-19 vaccination in patients with IMRD. A consensus was built through the Delphi method and involved four rounds of anonymous voting, where five options were used to determine the level of agreement (LOA), based on the Likert Scale: (1) strongly disagree; (2) disagree, (3) neither agree nor disagree (neutral); (4) agree; and (5) strongly agree. Nineteen questions were addressed and discussed via teleconference to formulate the answers. In order to identify the relevant data on COVID-19 vaccines, a search with standardized descriptors and synonyms was performed on September 10th, 2021, of the MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and LILACS to identify studies of interest. We used the Newcastle-Ottawa Scale to assess the quality of nonrandomized studies.

RESULTS

All the nineteen questions-answers (Q&A) were approved by the BSR Task Force with more than 80% of panelists voting options 4-agree-and 5-strongly agree-, and a consensus was reached. These Guidelines were focused in SMD on the most appropriate timing for IMRD patients to get vaccinated to reach the adequate covid-19 vaccination response.

CONCLUSION

These guidelines were developed by a BSR Task Force with a high LOA among panelists, based on the literature review of published studies and expert opinion for COVID-19 vaccination in IMRD patients. Noteworthy, in the pandemic period, up to the time of the review and the consensus process for this document, high-quality evidence was scarce. Thus, it is not a substitute for clinical judgment.

Spectrum of Mucocutaneous Reactions to COVID-19 Vaccination: A Report from a Web-Based Study from India

Background

With the COVID-19 vaccination taking stride all across the globe, there are multiple reports of vaccine-induced adverse reactions (cutaneous and systemic).

Objectives

To study the frequency and characteristics of mucocutaneous reactions to COVID-19 vaccines.

Methods

An online questionnaire-based study was performed among the recipients of COVID-19 vaccines.

Results

Majority (73.6%) of the responders had received the Covishield vaccine (AstraZeneca-Oxford), while 26.4% had been vaccinated with Covaxin (Bharat Biotech-ICMR). One or more post-vaccination mucocutaneous effects were experienced in 87 (19.6%) participants. Vaccine-associated mucocutaneous changes were observed in 19.7% and 22.2% of individuals who received Covishield and Covaxin, respectively. Local injection site reaction was the predominant mucocutaneous finding, followed by urticarial rash, exacerbation of preexisting dermatoses, morbilliform rash, apthous ulcers, pityriasis rosea like eruption, telogen effluvium, herpes zoster, purpuric rash, erythema multiforme and others. Anaphylaxis was reported in three individuals. However, fatality was not reported in any of the vaccine recipients. Intergroup assessment of parameters with respect to type of vaccine was found to be insignificant.

Conclusion

Majority reported mild and self-limiting reactions. This outcome should not discourage the common man in getting vaccinated.

Annular plaques mimicking Rowell's syndrome in the course of coronavirus disease 2019 mRNA vaccines: An overlooked phenomenon?

Effective vaccines for prevention of severe course and lethal outcome of coronavirus disease 2019 have been developed and approved in regulatory rolling and fast-track procedures; they are now widely distributed worldwide. Data about cutaneous side-effects of the new mRNA-type vaccines is scant, however. We herein report two similar cases of cutaneous adverse drug reactions (ADR) mimicking Rowell's syndrome that occurred after the first dose of BNT162b2 and mRNA-1273, respectively. Both patients achieved prompt clinical improvement with a short pulse of oral prednisolone and non-steroidal inflammatory drugs. We suspect this phenomenon to occur in a timeframe of 7-14 days after vaccination due to an interferon-γ-driven shift towards type I immunity in susceptible individuals. As rheumatic patients were excluded from phase III clinical trials and as most countries prioritized the elderly population to receive the vaccinations first, cutaneous ADR might become more frequent once the younger part of the population is vaccinated over the course of 2021. Atypical cutaneous ADR might be misinterpreted or overlooked by non-dermatologists. Further studies are required to determine the best suitable vaccine types for individual groups of patients.

Cutaneous findings following COVID-19 vaccination: review of world literature and own experience

There is growing evidence that not only the novel coronavirus disease (COVID‐19) but also the COVID‐19 vaccines can cause a variety of skin reactions. In this review article, we provide a brief overview on cutaneous findings that have been observed since the emerging mass COVID‐19 vaccination campaigns all over the world. Unspecific injection‐site reactions very early occurring after the vaccination are most frequent. Type I hypersensitivity reactions (e.g. urticaria, angio‐oedema and anaphylaxis) likely due to allergy to ingredients may rarely occur but can be severe. Type IV hypersensitivity reactions may be observed, including delayed large local skin lesions (“COVID arm”), inflammatory reactions in dermal filler or previous radiation sites or even old BCG scars, and more commonly morbilliform and erythema multiforme‐like rashes. Autoimmune‐mediated skin findings after COVID‐19 vaccination include leucocytoclastic vasculitis, lupus erythematosus and immune thrombocytopenia. Functional angiopathies (chilblain‐like lesions, erythromelalgia) may also be observed. Pityriasis rosea‐like rashes and reactivation of herpes zoster have also been reported after COVID‐19 vaccination. In conclusion, there are numerous cutaneous reaction patterns that may occur following COVID‐19 vaccination, whereby many of these skin findings are of immunological/autoimmunological nature. Importantly, molecular mimicry exists between SARS‐CoV‐2 (e.g. the spike‐protein sequences used to design the vaccines) and human components and may thus explain some COVID‐19 pathologies as well as adverse skin reactions to COVID‐19 vaccinations.

Linked Commentary: P. Gisondi et al. J Eur Acad Dermatol Venereol 2022; 36: 165–166. https://doi.org/10.1111/jdv.17854.

Single-Center Clinico-Pathological Case Study of 19 Patients with Cutaneous Adverse Reactions Following COVID-19 Vaccines

(1) Background: Coronavirus disease 2019 (COVID-19) vaccines are currently employed on a population-wide scale in most countries worldwide. Data about unusual cutaneous adverse drug reactions (ADR) are scant, though. (2) Methods: We retrospectively analyzed moderate to severe vaccine-related ADR in the Department of Dermatology and Allergy of the University Hospital Bonn between May to June 2021 and analyzed related skin biopsies. (3) Results: As a specialized dermatological academic center, we encountered a total of n = 19 clinically and pathologically heterogeneous cutaneous ADR with a female predominance. Delayed cutaneous ADR occurred as late as 30 days after vaccination. The majority of ADR were mild, though a few patients required systemic treatment (antihistamines, glucocorticosteroids). (4) Conclusions: The clinico-pathological spectrum of cutaneous side effects with COVID-19 vaccines is wide; however, the benefits outweigh the risks by far. More dermatopathological studies on cutaneous ADR not limited to COVID-19 vaccines are desirable to enable a better understanding of underlying pathophysiological mechanisms.

Diffuse Lymphadenopathy Syndrome as a Flare-Up Manifestation in Lupus and Mixed Connective Tissue Disease Following Mild COVID-19

BACKGROUND Manifestations of Coronavirus disease 2019 (COVID-19), caused by the SARS-CoV-2 virus, are highly variable among healthy populations. In connective tissue disease patients, the spectrum of clinical manifestations is even broader. In mild COVID-19 patients, diffuse lymphadenopathy (DL) has not been described as a late manifestation, and only severe COVID-19 has been associated with lupus flare-ups. Herein, we report 3 cases of connective tissue disease patients that presented with DL after diagnosis and complete resolution of mild COVID-19 disease. CASE REPORT Case 1. A 28-year-old man with inactive lupus, mixed connective tissue disease (MCTD), and a history of lung and cutaneous involvement. He presented with fever, polyarthralgia, and multiple lymphadenopathies 3 weeks after COVID-19 disease resolution. After evaluation, immunosuppressive treatment was initiated, with rapid response. Case 2. A 25-year-old woman with inactive lupus with a history of articular, hematologic, and cutaneous involvement. Four weeks after resolution of COVID-19 disease, she presented with malaise and cervical lymphadenopathies. After laboratory testing and imaging, she was treated for lupus flare-up, with rapid response. Case 3. A 68-year-old woman with inactive lupus with a history of articular and cutaneous involvement. Four weeks after COVID-19 resolution, she presented with malaise and cervical and axillary lymphadenopathies. After extensive evaluation, immunosuppressive treatment resulted in a rapid response. CONCLUSIONS After 3 to 4 weeks of mild, outpatient-treated COVID-19 and complete resolution of symptoms, 3 patients with connective tissue disease presented diffuse lymphadenopathy associated with inflammatory and constitutional symptoms. Infectious and neoplastic causes were thoroughly ruled out. All patients responded to reintroduction of or an increase in immunosuppressive therapy. We recommend considering the diffuse lymphadenopathy as a possible post-acute COVID-19 syndrome (PACS) manifestation in these patients, mainly when they are in the inactive phase.

Cutaneous Adverse Reactions to COVID-19 Vaccines: Insights from an Immuno-Dermatological Perspective

(1) Background: Numerous vaccines are under preclinical and clinical development for prevention of severe course and lethal outcome of coronavirus disease 2019 (COVID-19). In light of high efficacy rates and satisfactory safety profiles, some agents have already reached approval and are now distributed worldwide, with varying availability. Real-world data on cutaneous adverse drug reactions (ADRs) remain limited. (2) Methods: We performed a literature research concerning cutaneous ADRs to different COVID-19 vaccines, and incorporated our own experiences. (3) Results: Injection site reactions are the most frequent side effects arising from all vaccine types. Moreover, delayed cutaneous ADRs may occur after several days, either as a primary manifestation or as a flare of a pre-existing inflammatory dermatosis. Cutaneous ADRs may be divided according to their cytokine profile, based on the preponderance of specific T-cell subsets (i.e., Th1, Th2, Th17/22, Tregs). Specific cutaneous ADRs mimic immunogenic reactions to the natural infection with SARS-CoV-2, which is associated with an abundance of type I interferons. (4) Conclusions: Further studies are required in order to determine the best suitable vaccine type for individual groups of patients, including patients suffering from chronic inflammatory dermatoses.