Vesiculobullous and Other Cutaneous Manifestations of COVID-19 Vaccines: a Scoping and Narrative Review

As coronavirus disease (COVID-19) vaccines continue to be administered, dermatologists play a critical role in recognizing and treating the cutaneous manifestations (CM) associated with the vaccines. Adverse cutaneous reactions of COVID-19 vaccines reported in the literature range from common urticarial to rare vesiculobullous reactions. In this study, we performed a (1) scoping review to assess the occurrences of vesicular, papulovesicular, and bullous CMs of COVID-19 vaccines and their respective treatments, and (2) a narrative review discussing other common and uncommon CMs of COVID-19 vaccines. Thirty-six articles were included in the scoping review, and 66 articles in the narrative review. We found that vesicular, papulovesicular, and bullous lesions are infrequent, reported mostly after the first dose of Moderna or Pfizer vaccines. Eleven of the 36 studies reported vesicular reactions consistent with activation or reactivation of the herpes zoster virus. Most vesicular and bullous lesions were self-limited or treated with topical corticosteroids. Other CMs included injection-site, urticarial or morbilliform reactions, vasculitis, toxic epidermal necrolysis, and flaring of or new-onset skin diseases such as psoriasis. Treatments for CMs included topical or oral corticosteroids, antihistamines, or no treatment in self-limited cases. Although most CMs are benign and treatable, the data on the effect of systemic corticosteroids and immunosuppressive therapies on the immunogenicity of COVID-19 vaccines is limited. Some studies report reduced immunogenicity of the vaccines after high-dose corticosteroids use. Physicians may consult local guidelines where available when recommending COVID-19 vaccines to immunosuppressed patients, and when using corticosteroids to manage the CMs of COVID-19 vaccines.

Suspected Anaphylactic Reaction Following Second Dose of the Pfizer-BioNTech (BNT162b2) Coronavirus Vaccine in a Geriatric Female

Description Anaphylaxis is a rare but serious adverse reaction that can occur following mRNA-based vaccination against coronavirus (COVID-19). This is a case of a geriatric patient presenting with hypotension and an urticarial rash with bullous lesions following a syncopal episode with incontinence. She received the second dose of the Pfizer-BioNTech (BNT162b2) COVID-19 vaccine three days prior, and first developed the skin abnormalities the morning after receiving the vaccine. She had no past history of anaphylaxis or allergies to vaccinations. Her presentation met the diagnostic criteria for anaphylaxis, according to the World Allergy Organization: she had acute onset illness involving the skin and was hypotensive with symptoms suggestive of end-organ dysfunction. The latest literature published on anaphylaxis to mRNA-based COVID-19 vaccination indicates that this is an extremely rare complication. From December 14, 2020, to January 18, 2021, 9 943 247 doses of the Pfizer-BioNTech vaccine and 7 581 429 doses of the Moderna vaccine were administered in the United States. Sixty-six of these patients met anaphylaxis criteria. Of these cases, 47 received the Pfizer vaccine and 19 received the Moderna vaccine. Unfortunately, the mechanisms of these adverse reactions remain poorly understood, although it is postulated that particular vaccine components such as polyethylene glycol or polysorbate 80 may be the underlying triggers. This case demonstrates the importance of recognizing anaphylactic signs and symptoms, as well as proper patient education about the benefits and potential, albeit rare, adverse effects, of vaccination.

Varicella zoster virus reactivation following COVID-19 vaccination: a report of 3 cases

BACKGROUND

The advent of vaccination against COVID-19 brought great expectations for the control of the pandemic. As novel vaccines, much of the associated side effects were unknown. Currently, an increasing number of reports from side effects of COVID-19 vaccines have been published, namely on cutaneous reactions. These are of utmost importance to increase our knowledge about possible undesirable effects and its prevention.

METHODS

We describe a series of 3 cases who presented with varicella zoster virus (VZV) reactivation following the first dose of 3 different COVID-19 vaccines.

RESULTS

Three patients sought their Family Doctor after developing typical lesions of VZV reactivation, following a period of 3-13 days after COVID-19 vaccination. None was under immunosuppressive therapy. The 3 patients recovered in a few weeks and the subsequent doses of the vaccines were administered, without recurrence of the symptoms.

CONCLUSIONS

These cases highlight the possibility of VZV reactivation after the first dose of COVID-19 vaccines. Family Doctors should be aware of this event and play an important role informing and reassuring local communities for this possible vaccine reaction.

Not Feeling Swell: Superior Vena Cava (SVC) Syndrome Falsely Attributed to COVID-19 Vaccine Reaction

BACKGROUND

The mass immunization campaign against Coronavirus disease 2019 (COVID-19) has resulted in more patients presenting to the emergency department (ED) with concern for a vaccine reaction.

CASE REPORT

A 68-year-old man presented to the ED reporting an allergic reaction to the COVID-19 vaccine. He initially noted swelling of his face, neck, and right arm after receiving the first dose of the vaccine. After his second dose of the vaccine, the swelling became more pronounced and prompted him to seek care. On examination, he had fullness of the neck and engorgement of the left external jugular vein, which were exacerbated when the patient raised his arms above his head, consistent with Pemberton's sign. Apart from the swelling of the head and neck, there were no other findings consistent with an allergic reaction. The presence of Pemberton's sign prompted a computed tomography scan of the chest with contrast, which revealed a paratracheal mass measuring 4.5 × 2.0 cm with marked narrowing of the superior vena cava (SVC). The patient was admitted to the hospital for SVC syndrome, and further workup revealed a non-small cell lung cancer. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Patients may misattribute their symptoms to a COVID vaccine reaction when they are, in fact, experiencing a more serious underlying disease. This case highlights the importance of a thorough physical examination and maintaining a broad differential diagnosis. In this case, the presence of Pemberton's sign raised suspicion for SVC syndrome, and prompted further workup.

Cutaneous lupus erythematosus-like reaction arising after COVID-19 vaccination

Multiple adverse cutaneous reactions have been described following vaccination against COVID‐19. This case report describes a reaction to the Pfizer‐BioNTech (BNT162b2) vaccine that histopathologically resembles cutaneous lupus erythematosus with vacuolar interface alteration, superficial to mid‐dermal perivascular and periadnexal lymphocytic infiltrate with clusters of CD123 positive cells, and mildly increased dermal mucin.

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Late inflammatory reactions (LIRs) in patients with soft tissue fillers after SARS-CoV-2 infection and vaccination: A systematic review of the literature

INTRODUCTION

Soft tissue fillers are used for cosmetic and reconstructive purposes, and soft tissue filler procedures are among the most common nonsurgical procedures in the USA. Although soft tissue filler procedures are relatively quick and safe, adverse events such as late inflammatory reactions have been reported with every filler product. Infections and vaccinations have been proposed as potential triggers for late inflammatory reactions (LIRs), and it is therefore not surprising that these adverse events have been reported after SARS-CoV-2 infection and vaccination. Therefore, this review aims to give a detailed overview of these cases.

MATERIALS AND METHODS

A literature search was undertaken on LIRs in patients with a history of soft tissue filler use after SARS-CoV-2 infection or vaccination. This systematic review was reported according to the PRISMA guidelines. We searched the electronic database PubMed from January 2020-August 2021. Data on patient characteristics, filler characteristics, clinical findings and treatment options were included.

RESULTS

This review included 7 articles with a total of 19 patients with LIRs after SARS-CoV-2 infection or vaccination. Three patients with postinfection LIRs and 16 patients with postvaccination LIRs were reported. These LIRS mainly occurred in females who had HA injections for cosmetic purposes. Three patients with postinfection LIRs had symptoms of facial swelling and/or lip angioedema in a matter of weeks. Sixteen patients reported reactions after SARS-CoV-2 vaccination (13 following Moderna vaccination and 3 after Pfizer vaccination, after both the first and second doses) from 13 hours up to three weeks. These patients presented with similar clinical symptoms as patients with postinfection LIRs. All patients were treated in a conservative manner.

DISCUSSION

This review shows a relationship between LIRs and SARS-CoV-2 infection and vaccination. In the case of vaccination, these adverse events have been reported only after Moderna and Pfizer vaccinations. The reported adverse events are generally minor and self-limiting, and we encourage patients with soft tissue fillers to participate in vaccination programs.

Chronic Spontaneous Urticaria Triggered by the AstraZeneca/Oxford COVID-19 Vaccine with Achieved Remission: A Case Report

New adverse reactions to the COVID-19 vaccines are being identified as vaccination rates increase worldwide. Recently, there have been two reports of Moderna (mRNA-1273) vaccine induced relapse of chronic spontaneous urticaria (CSU) that was previously well controlled. Herein, we report a case of AstraZeneca/Oxford (ChAdOx1) vaccine triggered CSU in a patient with no history of CSU with achieved remission.

Cutaneous adverse events related to COVID-19 vaccines: A cross-sectional questionnaire-based study of 867 patients

Considering the emergency approval of the Food and Drug Administration for widespread use of coronavirus disease 2019 (COVID-19) vaccines, evaluating potential vaccine-related adverse effects is critical as it will allow physicians to diagnose and manage these complications properly. In this descriptive cross-sectional questionnaire-based study, we evaluated the possible side effects of the COVID-19 vaccine from June 1, 2021 to June 21, 2021. The Iranian population is generally vaccinated with AstraZeneca, Sputnik V, Sinopharm, and Bharat vaccines. The continuous and categorical variables were described and data analyzed by the SPSS software version 25. Cutaneous reactions occurred in 30% of individuals vaccinated against COVID-19. The most common cutaneous complications were focal injection site reaction, exanthematous rash, and urticaria. There were infrequent cutaneous adverse events that included vesicular eruption, pernio-like lesions, angioedema, erythema multiforme-like eruption, and zoster. Acquainting physicians with COVID-19 vaccine-related cutaneous complications will assist them in detection and management. In addition, introducing these complications to individuals might improve acceptance of vaccine-related adverse effects in the general population.

Cutaneous reactions reported after Moderna and Pfizer COVID-19 vaccination: A registry-based study of 414 cases

Background

Cutaneous reactions after messenger RNA (mRNA)-based COVID-19 vaccines have been reported but are not well characterized.

Objective

To evaluate the morphology and timing of cutaneous reactions after mRNA COVID-19 vaccines.

Methods

A provider-facing registry-based study collected cases of cutaneous manifestations after COVID-19 vaccination.

Results

From December 2020 to February 2021, we recorded 414 cutaneous reactions to mRNA COVID-19 vaccines from Moderna (83%) and Pfizer (17%). Delayed large local reactions were most common, followed by local injection site reactions, urticarial eruptions, and morbilliform eruptions. Forty-three percent of patients with first-dose reactions experienced second-dose recurrence. Additional less common reactions included pernio/chilblains, cosmetic filler reactions, zoster, herpes simplex flares, and pityriasis rosea-like reactions.

Limitations

Registry analysis does not measure incidence. Morphologic misclassification is possible.

Conclusions

We report a spectrum of cutaneous reactions after mRNA COVID-19 vaccines. We observed some dermatologic reactions to Moderna and Pfizer vaccines that mimicked SARS-CoV-2 infection itself, such as pernio/chilblains. Most patients with first-dose reactions did not have a second-dose reaction and serious adverse events did not develop in any of the patients in the registry after the first or second dose. Our data support that cutaneous reactions to COVID-19 vaccination are generally minor and self-limited, and should not discourage vaccination.

Histopathologic Lesion Scoring and Histomorphometric Methods for Measuring Vaccine Reactions in the Trachea of Broiler Chickens

Severity of the tracheal histologic inflammatory response induced in broilers by ocular inoculation of two infectious bronchitis (IBV) and three Newcastle disease virus (NDV) commercial vaccines were evaluated. The vaccine was delivered by eye drop with a coarse spray to day-old chicks. The vaccines were given individually or in various combinations and were evaluated relative to nonvaccinated controls. Evaluations were performed on postvaccination (PV) days 7 and 14. Histologic endpoints included semiquantitative severity scoring of inflammatory components and quantitative morphometric determinations of inflammatory cell concentration, mucosal thickness, and percentage of ciliated mucosal surface. Strong positive correlations were observed between routine severity scoring and morphometric inflammatory parameters, whereas a negative correlation was present between inflammation severity and the percentage of mucosal ciliation. Variable, sometimes extensive, and often statistically significant differences in inflammatory responses were observed between the various vaccines. One IBV Massachusetts strain vaccine (IBV-A) produced the greatest overall inflammatory response when given alone or in combination with the NDV vaccines. Enhancement of tracheitis was seen on PV day 14 by covaccination of IBV-A with the NDV vaccines, but not by covaccination of another IBV Massachusetts strain vaccine (IBV-B) with NDV. Reduction in cilia percentage was observed for all vaccine groups relative to controls on PV day 7. However, although reactive cilia regeneration occurred on PV day 14 for most vaccine groups, a cilia regenerative response was not apparent for individual or NDV combination vaccination for IBV-A. The study also demonstrates that substantial microscopic trachea pathology may be present in vaccinated birds not exhibiting apparent clinical respiratory signs.

Identification of blue staining vaccine-derived material in inflammatory lesions using cultured canine macrophages

BACKGROUND

Vaccine reactions are described in cytology textbooks as having eosinophilic to magenta colored globules within and admixed with inflammatory cells. Recently, we have seen increased numbers of inflammatory lesions containing blue to blue-gray globular material, with historical information suggesting an association with rabies vaccination.

OBJECTIVES

The purpose of the study was to confirm the blue-gray and the eosinophilic material observed microscopically in some inflammatory lesions as being vaccine-derived.

METHODS

Three different vaccines were cytocentrifuged and Wright stained. Vaccine aliquots were also added to the culture media of canine-derived macrophages for 24 hours and the cells subsequently harvested, cytocentrifuged, and Wright stained. The globular material present in both preparations was compared to that observed in vaccine-induced inflammatory lesions. Morin staining was used to identify metal within vaccine material in both in vitro- and in vivo-derived cytology samples.

RESULTS

Vaccine-derived material has a characteristic color and appearance. Appearance of the material was consistent in cytologic samples, in cells incubated with the vaccine, and in cytocentrifuged preparations of the vaccine vial contents. The blue-gray globules stained positively for Morin stain, while the eosinophilic material did not stain.

CONCLUSIONS

Vaccine-induced inflammatory lesions may contain blue to blue-gray or magenta stained globular material. Blue-gray material was associated with administration of rabies vaccine Imrab 3 TF and the observed material may be metal-containing adjuvant. Magenta material was associated with other vaccines and negative for Morin stain, suggesting a metal-free adjuvant.

Vaccine quality and safety: scrutinizing the reported 3-fold increase in adverse effects following immunization (Aefi) in India

BACKGROUND

There has been major controversy over vaccine safety in India following newspaper reports citing right to information (RTI) disclosure that there have been increasing vaccine related deaths following immunization in children in the recent years.

METHODS

Secondary data analysis.

RESULTS AND CONCLUSION

Adverse effect following immunization (AEFI) events in recent years are being linked to closure of three government owned vaccine producing public sector units (PSU) closures in India. The media reports quoting government sources suggest that the total number of reported deaths due to AEFI in a pre-closure of vaccine PSUs 7 years (2001-2007) was 136, whereas it is 355 in the post vaccine PSU closure 3 years (2008 to 2010). There is an issue of comparability of numbers of AEFI deaths pre- (2001-2007) and post-vaccine PSU closure era (2008-2011) and linking increased AEFI deaths to vaccine PSU closure.