Leukocytoclastic vasculitis as a cutaneous manifestation of ChAdOx1 nCoV-19 corona virus vaccine (recombinant)

Management of coronavirus disease 2019 vaccine-induced cutaneous complications: A comprehensive literature review

Despite the numerous reports of cutaneous manifestations associated with vaccines for coronavirus disease 2019 (COVID-19), the relationship between COVID-19 vaccines and cutaneous side effects remains unevaluated. In this review, we examine these manifestations and their management. Reported dermatoses included injection-site reaction (early and delayed), type I allergic reaction, morbilliform eruption, pityriasis rosea, Sweet syndrome, lichen planus, psoriasis, herpes zoster reactivation, erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis (TEN). The most common COVID-19 vaccination-related cutaneous manifestations are delayed local reactions, approximately 66% of which are associated with the Moderna vaccine, and 33% with the Pfizer vaccine. Aside from mild injection-site reactions, severe reactions include anaphylaxis and TEN. Most reactions, except for Stevens-Johnson syndrome and anaphylaxis, though unpredictable and unpreventable are mild and can be treated symptomatically. Findings from this review should allow primary care physicians and dermatologists to reach faster diagnosis and initiate prompt intervention.

Histopathological Patterns of Cutaneous Adverse Reaction to Anti-SARS-CoV-2 Vaccines: The Integrative Role of Skin Biopsy

The advent of vaccines represented a milestone to allow the slowing down and then containing of the exponential increase in ongoing infections and deaths of COVID-19. Since the first months of the vaccination campaign in various continents, there has been a certain number of reports of adverse events, including skin reactions. We conducted a systematic review, searching on PubMed, Web of Science, Scopus, and Cochrane Library for the words: COVID vaccine, dermatopathology, skin, eruptions, rash, cutaneous, BNT162b2 (Pfizer-BioNTech), ChAdOX1 (AstraZeneca), and mRNA-1273 (Moderna). A total of 28 records were initially identified in the literature search of which two were duplicates. After screening for eligibility and inclusion criteria, 18 publications were ultimately included. Various clinical cutaneous manifestations and histopathological patterns following vaccination have been described in literature. The most frequent clinical-pathological presentations were erythematous maculo-papular eruptions in different way of distribution with histopathological pictures mostly represented by interface changes and mixed peri-vascular and peri-adnexal cell infiltrate. Other presentations included new onset of pemphigoid bullous disease (n = 15), delayed T-cell-mediated hypersensitivity reaction (injection site reactions) (n = 10), purpuric skin rash (n = 13), mostly localized on the legs bilaterally and symmetrically with histological pictures characterized by extravasation of erythrocytes in the superficial and middle dermis, and other types of reactions. New studies with large case series and further literature reviews are needed to improve the clinical management of patients and optimize the timeline for carrying out histological biopsy for confirmatory, supportive, and differential diagnosis purposes.

A Systematic Review of Histopathologic Surveys on Mucocutaneous Biopsies in Patients Developed COVID-19 Vaccine-Related Dermatologic Manifestations

ABSTRACT

Coronavirus 2 is an infectious agent primarily identified as the cause of a pandemic viral pneumonia. With the mass vaccination against this virus, one of the health issues is the safety of currently available vaccines considering their adverse reactions. This systematic review was conducted to assess and summarize all reported data on histopathologic findings associated with mucocutaneous reactions that developed after COVID-19 vaccination for a better pathophysiology interpretation and clinical management of these reactions. A systematic search was performed in PubMed, Web of Science, and Scopus databases as well as Google Scholar engine for relevant English articles published till July 1, 2022. This review includes 131 studies with a total number of 287 cases. Eruptions that underwent a biopsy were mostly described as erythematous maculopapular, papulosquamous, vasculitis-like, lichenoid, or urticarial lesions. Histopathology revealed spongiosis, interstitial, and perivascular lymphohistiocytic infiltration, erythrocyte extravasation, parakeratosis, endothelial inflammation, and the like. Findings were highly consistent with morbilliform erythema, psoriasiform dermatosis, leukocytoclastic vasculitis, and lichenoid or urticarial drug reactions. The majority of these reactions had a mild nature and were primarily observed in patients with underlying health conditions. Microscopic evaluation was also consistent with transient inflammatory changes, and features like neutrophilic infiltrates, subcorneal pustules, and vasculopathy were less frequently reported than what seen in COVID infection. Therefore, dermatologic reactions developing after vaccination in the general population should not hinder a complete vaccination.

Cutaneous small vessel vasculitis

This review discusses the clinical manifestations of cutaneous small vessel vasculitis. The etiologies and work up will be explored as well as the treatment considerations. This entity is multifactorial and usually involves multiple specialties. The presentation can range from self-limited to life threatening, multi-organ failure. It is essential to be able to diagnose vasculitis and proceed with the appropriate laboratory studies and work-up. Finally, investigation of associated etiologies such as infection and drugs will guide additional diagnostic studies.

Cutaneous vasculitis: Lessons from COVID-19 and COVID-19 vaccination

Cutaneous vasculitis (CV) is an inflammatory skin-limited vascular disease affecting the dermal and/or hypodermal vessel wall. From the pathogenetic point of view, idiopathic forms are described as well as the induction from various triggers, such as drugs, infections, and vaccines. Following SARS-CoV-2 pandemic outbreak, cases of CV induced by both COVID-19 and COVID-19 vaccinations have been reported in literature. The aim of our work was to collect multiple cases available in the literature and analyze the frequency of the different forms of induced vasculitis, as well as their histological and immunopathological features. Although rare, CV induced by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and vaccines may provide interesting insights into the pathogenesis of these inflammatory processes that may in the future be useful to understand the mechanisms underlying cutaneous and systemic vasculitis.

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.

Cutaneous vasculitis and vasculopathy in the era of COVID-19 pandemic

Cutaneous vasculitides encompass a heterogeneous group of clinicopathological entities, which may occur as single-organ vasculitis of the skin or present as skin-limited variant of systemic vasculitis (i.e., skin-limited ANCA-associated vasculitis), and are triggered by various factors, including infections, drugs and vaccines. The COVID-19 pandemic has challenged us with a variety of both disease- and vaccine-associated skin manifestations, including vasculitis. Among the latter, cutaneous small-vessel vasculitis, previously known as leukocytoclastic vasculitis, seems to be the most reported in either scenario, i.e., natural infection and vaccination. Vasculopathy without true vasculitic changes on histology develops in but a minority of cases, mostly severe/critical COVID-19 patients, and appears to be the result of endothelial injury due to pauci-immune thromboembolic mechanisms. Herein, we provide an overview of the available literature on COVID-19-associated and anti-SARS-CoV-2-vaccine-associated cutaneous vasculitis. Although evidence is mostly limited to isolated reports, with a proportion of cases lacking histopathological confirmation, ample overlap with pre-pandemic forms is shown.

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.

Extensive cutaneous leukocytoclastic vasculitis after Sinopharm vaccine: case report and review of the literature

Cutaneous leukocytoclastic vasculitis (LCV) has been reported as a rare form of cutaneous reaction to different SARS-Cov-2 vaccines. Herein, we present the first case of cutaneous LCV following BBIBP-CorV (Sinopharm) vaccine, that occurred in a female patient with no prior comorbidities. A literature review about similar cases following different COVID-19 vaccines is discussed. This article is protected by copyright. All rights reserved.

SARS‐CoV ‐2 Vaccination‐Induced Cutaneous Vasculitis: Report of two new cases and literature Review

Currently the most powerful tool in combating the COVID‐19 pandemic is vaccination against SARS‐CoV‐2. A growing percentage of the world's population is being vaccinated. Various vaccines are worldwide on the market. Several adverse reactions have been reported as a part of post‐marketing surveillance of COVID‐19 vaccines. Among the possible adverse events, cutaneous vasculitis has occasionally been reported. We present a narrative review on cutaneous vasculitis related to COVID‐19‐vaccination to summarize clinical findings, histopathology, treatment and outcome. We searched for “COVID vaccine”, “COVID vaccination” AND “cutaneous vasculitis” in PUBMED. Articles in English have been selected, from inception to December 2021, and analyzed for patient's characteristics, type of vaccine, time of appearance of cutaneous vasculitis and clinico‐histopathologic type. Treatment and outcome have also been considered in this narrative review. Two new unpublished cases of ours were added. Cutaneous vasculitis is a rare adverse event to COVID‐19 vaccination. It has been observed with mRNA and adenovirus‐vector vaccines. IgA vasculitis, lymphocytic and ANCA‐associated vasculitis, leukocytoclastic and urticarial vasculitis have been reported. This adverse event can occur after first or second shot. Most cases run a mild to moderate course. Cornerstone of medical treatment are systemic corticosteroids. Complete remission could be achieved in most patients. Vasculitis may not be considered as a contraindication of vaccination, being uncommonly reported and shows a favorable prognosis. The benefit of the vaccination remains high especially for immunocompromised patients. COVID‐vaccine induced vasculitis is important in the differential diagnosis of purpuric and vasculitis disorders.

Cutaneous Complications of mRNA and AZD1222 COVID-19 Vaccines: A Worldwide Review

Because of the increasing emergence of cutaneous reactions from COVID-19 vaccines worldwide, we investigated the published reports of these complications. We searched the PubMed, Google Scholar, and Scopus databases and the preprint server bioRxiv for articles on cutaneous complications linked to mRNA-1273 (Moderna), BNT162b2 (Pfizer–BioNTech), and AZD1222 (AstraZeneca–Oxford University) vaccines published until 30 September 2021. Eighty studies describing a total of 1415 reactions were included. Cutaneous reactions were more prevalent in females (81.6%). Delayed large local reactions were the most common complication (40.4%), followed by local injection site reactions (16.5%), zoster (9.5%), and urticarial eruptions (9.0%). Injection site and delayed large local reactions were predominantly caused by the mRNA-1273 vaccine (79.5% and 72.0%, respectively). BNT162b2 vaccination was more closely linked to distant reactions (50.1%) than mRNA-1273 (30.0%). Zoster was the most common distant reaction. Of reactions with adequate information for both vaccine doses, 58.3% occurred after the first dose only, 26.9% after the second dose only, and 14.8% after both doses. Overall, a large spectrum of cutaneous reaction patterns occurred following the COVID-19 vaccination. Most were mild and without long-term health implications. Therefore, the occurrence of such dermatologic complications does not contraindicate subsequent 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.

Leukocytoclastic vasculitis (cutaneous small-vessel vasculitis) after COVID-19 vaccination

Vaccinations may induce cutaneous adverse events, due to nonspecific inflammation or immuno-mediated reactions. Several types of vasculitis have been observed. We report on a 71-year-old woman who developed cutaneous small-vessel vasculitis after the second dose of Vaxzevria COVID-19 vaccination, showing leukocytoclastic vasculitis on histopathological examination of a skin biopsy.

Cutaneous small-vessel vasculitis is a rare condition which can be idiopathic or secondary to underlying infections, connective tissue disorders, malignancy, and medications. The pathogenesis involves immune complex deposition in small blood vessels, leading to activation of the complement system and recruitment of leukocytes.

Exacerbation of small-vessel vasculitis has been reported following the administration of various vaccines, particularly influenza vaccine. It is expected that SARS-CoV-2 vaccine results in the activation of B- and T-cells and antibody formation. We hypothesize that leukocytoclastic vasculitis caused by immune complex deposition within cutaneous small vessels could be a rare side effect of Vaxzevria COVID‐19 vaccination.