Delayed systemic urticarial reactions following mRNA COVID-19 vaccination

Right Biceps Pseudo-Tumor from COVID-19 Vaccination

Delayed hypersensitivity reactions (DHRs) have been reported in association with COVID-19 vaccines, particularly those that are mRNA-based. Classic DHRs result in induration, erythema, tenderness, and urticaria. However, soft tissue mass is an uncommon complication of a COVID-19 vaccination-associated DHR and is rarely reported in the literature. We present a case of a 49-year-old male who recognized a mildly painful, firm soft tissue mass within the biceps mimicking neoplasm six months after receiving the booster dose of the Moderna vaccine. Non-operative conservative treatment modalities, including heating pads, ice packs, acetaminophen, and ibuprofen, failed to improve the patient's mass. The mass, which proved histologically to be an inflammatory pseudo-tumor, did not recur after complete excision. While there have been many reported cases of DHRs following COVID-19 vaccinations, we present this case to raise awareness of the development of pseudo-tumors as a possible, yet rare, clinical manifestation of DHRs following vaccination.

The Long Road of Long COVID: Specific Considerations for the Allergist/Immunologist

Long COVID (coronavirus disease 2019) syndrome, also known as post-acute sequelae of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, is a new disorder that can develop after an acute infection with the SARS-CoV-2 virus. The condition is characterized by multiorgan system involvement with a wide range of symptoms that can vary in severity from mild to debilitating. Some of the common symptoms associated with long COVID syndrome include cardiovascular issues such as heart palpitations and chest pain; thrombotic events (eg, blood clotting disorders); metabolic problems (eg, type 2 diabetes); dysautonomia; paroxysmal orthostatic tachycardia syndrome; myalgic encephalomyelitis/chronic fatigue syndrome; reactivation of the Epstein-Barr virus; the presence of autoantibodies; chronic spontaneous urticaria (hives); and connective tissue diseases. Whereas long COVID syndrome can affect individuals from various backgrounds, certain populations may be at higher risk such as individuals of Hispanic and Latino heritage, as well as those with low socioeconomic status, although approximately one-third of affected patients have no known risk factors or preexisting conditions. Many survivors of COVID-19 struggle with multiple symptoms, increased disability, reduced function, and poor quality of life. Whereas vaccination has been the most significant intervention able to decrease the severity of acute SARS-Cov2 infection and curtail deaths, limited data are available related to its modulating effect on long COVID necessitating the need for further investigation. Furthermore, several inflammatory pathways have been proposed for the pathogenesis of long COVID that are the targets for ongoing clinical studies evaluating novel pharmacological agents. The purpose of the present report is to review the many factors associated with long COVID with a focus on those aspects that have relevance to the allergist-immunologist.

How Infection and Vaccination Are Linked to Acute and Chronic Urticaria: A Special Focus on COVID-19

Since more than a century ago, there has been awareness of the connection between viral infections and the onset and exacerbation of urticaria. Our knowledge about the role of viral infection and vaccination in acute and chronic urticaria improved as a result of the COVID-19 pandemic but it has also highlighted knowledge gaps. Viral infections, especially respiratory tract infections like COVID-19, can trigger the onset of acute urticaria (AU) and the exacerbation of chronic urticaria (CU). Less frequently, vaccination against viruses including SARS-CoV-2 can also lead to new onset urticaria as well as worsening of CU in minority. Here, with a particular focus on COVID-19, we review what is known about the role of viral infections and vaccinations as triggers and causes of acute and chronic urticaria. We also discuss possible mechanistic pathways and outline the unmet needs in our knowledge. Although the underlying mechanisms are not clearly understood, it is believed that viral signals, medications, and stress can activate skin mast cells (MCs). Further studies are needed to fully understand the relevance of viral infections and vaccinations in acute and chronic urticaria and to better clarify causal pathways.

Hypersensitivity reactions to anti-SARS-CoV-2 vaccines: Basophil reactivity to excipients

Basophil activation test (BAT) can tackle multiple mechanisms underlying acute and delayed hypersensitivity to drugs and vaccines and might complement conventional allergy diagnostics but its role in anti-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine-related hypersensitivity is ill-defined. Therefore, 89 patients with possible hypersensitivity (56 % with delayed mucocutaneous manifestations) to anti-SARS-CoV-2 vaccines were tested with BAT for Macrogol 3350, DMG-PEG 2000, PEG 20000, polysorbate-80 and trometamol and compared to 156 subjects undergoing pre-vaccine BAT. A positive BAT was associated with delayed reaction onset (p = 0.010) and resolution (p = 0.011). BAT was more frequently positive to DMG-PEG 2000 than to other excipients in both groups (p < 0.001). DMG-PEG 2000 reactivity was less frequent in vaccine-naïve (6 %) than vaccinated subjects (35 %, p < 0.001) and associated with mRNA-1273 vaccination. DMG-PEG 2000 BAT might therefore have a diagnostic role in subjects with delayed hypersensitivity reactions. Natural immunity might be a key player in basophil activation.

Vaccine confidence among those living with allergy during the COVID pandemic (ACCORD): A scoping review

Background

Reports of allergic reactions to coronavirus disease 2019 (COVID-19) vaccines, coupled with an "infodemic" of misinformation, carry the potential to undermine confidence in the COVID-19 vaccines. However, no attempts have been made to comprehensively synthesize the literature on how allergic disease and fear of allergic reactions to the vaccines contribute to hesitancy.

Objectives

Our aim was to review the academic and gray literature on COVID-19 vaccine hesitancy and allergic reactions.

Methods

We searched 4 databases (CINAHL, PsycINFO, MEDLINE, and Embase) using a search strategy developed by content and methodologic experts. No restrictions were applied regarding COVID-19 vaccine type, country of study, or patient age. Eligible articles were restricted to 10 languages.

Results

Of the 1385 unique records retrieved from our search, 60 articles (4.3%) were included. Allergic reactions to the COVID-19 vaccine were rare but slightly more common in individuals with a history of allergic disease. A fifth of the studies (13 of 60 [22%]) discussed vaccine hesitancy due to possibility of an allergic reaction. Additionally, the present review identified research on details of vaccine-related anaphylaxis (eg, a mean and median [excluding clinical trial data] of 12.4 and 5 cases per million doses, respectively) and allergic reactions (eg, a mean and median [excluding clinical trial data] of 489 and 528 cases per million doses, respectively).

Conclusion

COVID-19 vaccine acceptance among individuals living with allergy and among those with no history of allergic disease may be affected by fear of an allergic reaction. Despite the low incidence of allergic reactions to the COVID-19 vaccine, fear of such reactions is one of the most commonly cited concerns reported in the literature.

Shoulder Pseudo-Tumor from COVID-19 Vaccine

Hypersensitivity reactions to the COVID-19 mRNA vaccines were identified in the initial 2020 trials. Appearance of a soft tissue mass is a rare manifestation of this hypersensitivity reaction. In this patient, bilateral injections resulted in the appearance of shoulder masses. Magnetic resonance imaging showed localized pseudo-tumorous edema in both shoulders, one subcutaneous and the other intramuscular. This is only the second case of a mass-like reaction to the COVID-19 vaccine mimicking a possible soft tissue neoplasm. Improper vaccination administration technique may have contributed to this complication. The case is presented to increase awareness of this potential pseudotumor.

Did the COVID-19 pandemic impact urticaria information-seeking behavior in China? A retrospective longitudinal study

Purpose

To investigate information-seeking behavior related to urticaria before and during the COVID-19 pandemic in China.

Methods

Search query data for terms related to urticaria were retrieved using Baidu Index database from October 23, 2017 to April 23, 2022, and daily COVID-19 vaccination doses data were obtained from the website of the Chinese Center for Disease Control and Prevention. Among the 23 eligible urticaria search terms, four urticaria themes were generated as classification, symptom, etiology, and treatment of urticarial, respectively. Baidu Search Index (BSI) value for each term were extracted to analyze and compare the spatial and temporal distribution of online search behavior for urticaria before and after the COVID-19 pandemic, and to also explore the correlation between search query and daily COVID-19 vaccination doses.

Results

The classification of urticaria accounted for nearly half of the urticaria queries on the internet. Regular seasonal patterns of BSI were observed in urticaria-related online search, by attaining its highest level in spring and summer and lowest level in winter. The BSIs of all urticaria themes significantly increased after the COVID-19 pandemic than that before the pandemic (all P<0.05). Xizang, Qinghai and Ningxia are the most active geographical areas for increased urticaria-searching activities after the COVID-19 pandemic. There was also a significant positive correlation between daily BSIs and daily COVID-19 vaccination doses in each urticaria theme. Cross-correlation analysis found that the search of symptom, etiology, and treatment attained their strongest correlation with daily COVID-19 vaccination doses at 11-27 days before the injection of vaccine, imply vaccination hesitation related to concerns of urticaria.

Conclusions

This study used the internet as a proxy to provide evidence of public search interest and spatiotemporal characteristics of urticaria, and revealed that the search behavior of urticaria have increased significantly after the COVID-19 pandemic and COVID-19 vaccination. It is anticipated that the findings about such increase in search behavior, as well as the behavior of urticaria-related vaccine-hesitancy, will help guide public health education and policy regulation.

Delayed Extensive Local Reaction to the mRNA-1273 Vaccine against SARS-CoV-2: A Case Report

In response to the COVID-19 pandemic, two mRNA vaccines (Comirnaty and Spikevax) received emergency use authorization from the European Medicines Agency. This case report aimed to report a delayed adverse reaction to the mRNA-1273 vaccine against COVID-19 from a Portuguese vaccination center.

A case report was performed with medical observation and reported to the Portuguese Pharmacovigilance System, then investigated based on the WHO-UMC Causality Categories. A 66-year-old female patient with a clinical history of dyslipidemia, essential arterial hypertension, obesity, multinodular goitre and cholecystectomy, who presented delayed large cutaneous hypersensitivity reaction following Spikevax COVID-19 mRNA (mRNA-1273) vaccine administration.

Our clinical findings (time and clinical appearance), along with evidence of previously reported histological findings, are strongly suggestive of T-cell-mediated hypersensitivity. There is no contraindication to the inoculation of subsequent doses in patients developing these clinical conditions, and vaccination should continue to be strongly encouraged.

COVID arm as a common cutaneous manifestation after mRNA-1273 vaccination: a systematic review

BACKGROUND

By August 2022, CoronaVirus Disease-2019 (COVID-19) had caused 600 million illnesses and 6.5 million fatalities globally. A massive vaccination program is being implemented worldwide to suppress this condition. Several works of literature stated that mRNA COVID-19 vaccination, specifically with the mRNA-1273 vaccine, is followed by clear evidence of the COVID arm effects associated with this vaccine.

OBJECTIVE

To analyze the latest evidence of COVID arm as a common effect of mRNA-1273 vaccination with the ultimate goal of improving vaccine counseling to help healthcare professionals and reassure patients.

METHODS

A comprehensive search was performed on topics that assess the COVID arm as a cutaneous manifestation following mRNA-1273 vaccination from inception up until July 2022.

RESULTS

Eighteen studies with a total of 1129 participants after the first and second dose of mRNA-1273 vaccination reported that most participants had COVID arm following the first dose administration. The characteristics of the patients were a mean age of 43.8 years old, and females represented ≥ 50% in most studies, with a mean onset of 6.9 days after the first dose administration. Symptoms resolved within seven days following the treatment and were harmless.

CONCLUSIONS

This study found that the COVID arm condition is most common following the first mRNA-1273 vaccination in the female and middle-aged group. The correlation between demographic variables and COVID arm risk elucidates that the reaction is a type IV allergic skin reaction.

Late Hypersensitivity Reactions to the BNT162b2 SARS-CoV-2 Vaccine Are Linked to Delayed Skin Sensitization and Prior Exposure to Hyaluronic Acid

Background: Late hypersensitivity reactions (HSRs) to the BNT162b2-vaccine have raised concerns regarding its safety, particularly as further immunizations are required. The yield of skin testing with the BNT162b2v is unclear, as well as the risk factors and outcomes of re-immunization after late HSRs. Objective: We studied a series of patients with late HSRs to BNT162b2v. Methods: Patients referred to the Sheba medical center from December 2020 to May 2021 with late HSRs to the first dose of BNT162b2 were included. HSRs were defined as late if they appeared or lasted >24 h after inoculation. We compared late HSRs to immediate HSRs that appeared within minutes−2 h after vaccination. Intradermal testing with PEG-containing medication and BNT162b2v was performed. Results: A total of 17 patients that presented with late HSRs (study group) were compared to 34 patients with immediate HSRs (control group). Delayed sensitivity to intradermal testing of the BNT162b2v was observed in 9/17 (53%) of the study group compared to 4/34 (12%) in the control group (p = 0.01). Former exposure to a dermal filler with hyaluronic acid was documented among 7/17 (41%) vs. 2/34 (6%) in the study and control groups, respectively, (p = 0.0038). All patients who presented with late HSRs were advised to receive subsequent doses of the BNT162b2v vaccine with or without concomitant medication, and all were re-immunized successfully. Conclusions: Late HSRs to BNT162b2v were linked with positive responses to intradermal testing with the vaccine and prior exposure to derma fillers with hyaluronic acid. This may elude to an immune mechanism triggered by former exposures. Although further studies are needed, late HSRs to the BNT162b2-vaccine did not prevent patients from receiving subsequent doses of the vaccines.

Cancer patients and COVID-19 vaccination, from safety to protocol adherence: A real-life setting report

Background

The SARS-CoV-2 pandemic has slowed down cancer prevention and treatment strategies; consequently, cancer patients are prioritized to get the COVID-19 vaccines. Being constantly threatened by a new outbreak, the dive within the immunogenicity response is of great value; nonetheless, evaluating the side effects of these vaccines on fragile patients will assure their adherence to the vaccination protocol.

Objectives

This study sets out to investigate the adverse events reported about the vaccine according to its doses and types, and to compare the prevalence and severity of toxicities across two subgroups of cancer patients, those who received the injection during active therapy cycles, and those who have not started the therapy yet at vaccination time, moreover, this paper examines the will and commitment of this population to the vaccination schemes.

Methods

This is an observational, retrospective, cohort study, in which we conducted a semi-constructed interview with 415 random solid cancer patients treated at the National Institute of Oncology in Morocco. The assessment of adverse events was carried out with a standardized scale.

Results

Eleven months after the launch of the campaign, 75.2% of patients received at least one dose of the vaccine. Altogether, the analysis demonstrates a significant difference between the adverse effects reported post the second dose compared to the first one (p=0.004; odds ratio=2 [95% CI: 1.23 - 3.31]). Besides, the results indicate an increase in the rank of the severity of systemic events (p<0.001, r=0.28) after the second dose, but not for the local events (p=0.92, r=0.005). In the adjusted subgroup analysis, no effect was detected linking active therapy with the occurrence of toxicity (p=0.51, v=0.04) as well as with the level of severity reported after both; the first and second dose. Due to the fear of interactions with the therapy, we noticed a significant trend to delay the booster dose among the participants who completed the initial vaccine protocol.

Conclusion

A considerable body of evidence exists to persuade cancer patients to take the Coronavirus vaccines, and to also follow their vaccination schemes under the supervision of their treating physicians.

Curbing COVID-19 Vaccine Hesitancy from a Dermatological Standpoint: Analysis of Cutaneous Reactions in the Vaccine Adverse Event Reporting System (VAERS) Database

OBJECTIVES

Adverse reactions to the COVID-19 vaccines have been of interest since their emergency authorization. Cutaneous manifestations of the vaccines are not well studied. We aimed to characterize cutaneous reactions to the Moderna (mRNA-1273) and the Pfizer-BioNTech (BNT162b2) COVID-19 vaccines on a large, national scale.

METHODS

The Vaccine Adverse Event Reporting System was filtered for cutaneous and hair and nail reactions to the COVID-19 vaccines. Patient demographics and past medical histories, vaccine manufacturer and dosing, symptom timing, reaction location, and patient outcomes were extracted from each report.

RESULTS

As of December 24, 2021, there were 67,273 cutaneous reactions to all COVID-19 vaccines, with most patients receiving the Moderna (mRNA-1273) or Pfizer-BioNTech (BNT162b2) vaccines. The most common reactions overall were injection-site reaction, urticaria, and papular rash, with injection-site reaction more common after the Moderna (mRNA-1273) vaccine, and all other cutaneous reactions more common after the Pfizer-BioNTech (BNT162b2) vaccine. Patients with past histories of psoriasis, urticaria, and local site reactions to a vaccine were more likely to report these same symptoms after the COVID-19 vaccine.

CONCLUSION

Patients should be counseled about these potential dermatologic reactions to the COVID-19 vaccines. Most occur within the first few days after vaccination, and are mild and self-limiting. Patients should therefore be encouraged that it is safe to receive the COVID-19 vaccine from a dermatological perspective.

Adverse Reactions to Anti-Infective Vaccines: an Emerging Problem in the COVID-19 Era

Purpose of review

Vaccines are an essential tool for preventing infectious diseases and reducing associated morbidity and mortality. Vaccination has a significant impact at both individual and community levels, and COVID‐19 vaccination programs are a new example of the great value of this public health strategy. However, adverse reactions, especially severe reactions such as anaphylaxis, prevent these programs from progressing properly, thus limiting vaccination uptake in the population.

Recent findings

The frequency of reactions and types of vaccine components, with special attention to COVID-19 vaccines studies, provides information on the magnitude and causes of adverse events. The understanding of mechanisms involved has made it possible to adequately guide diagnosis, especially to COVID-19 vaccine components, such as polyethylene glycol, trometamol, and polysorbate-80.

Summary

This review focuses on adverse reactions to vaccines, with emphasis on allergic reactions. A diagnostic pathway is suggested that, on the one hand, enables to take the necessary precautions in persons with a history of allergy to vaccine components or allergic reactions to vaccines and, on the other, supports administration of subsequent doses. The overall objective is to ensure that people with allergy can be vaccinated in the same way as the rest of the population, and that they are offered alternatives where necessary.