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LETTER TO EDITOR Table of Contents  
Ahead of print publication
Cutaneous leukocytoclastic vasculitis after ChAdOx1 nCoV-19 vaccine


 Department of Medicine, Sultan Qaboos Hospital, Salalah, Oman

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Date of Submission15-Jul-2022
Date of Decision31-Jul-2022
Date of Acceptance19-Aug-2022
Date of Web Publication18-Oct-2022
 


How to cite this URL:
Abdulla MC. Cutaneous leukocytoclastic vasculitis after ChAdOx1 nCoV-19 vaccine. Indian J Med Spec [Epub ahead of print] [cited 2022 Dec 5]. Available from: http://www.ijms.in/preprintarticle.asp?id=358782




Sir,

Flaring up of preexisting leukocytoclastic vasculitis has been reported following the BNT162b2 mRNA COVID-19 vaccine.[1] To date, leukocytoclastic vasculitis has not been associated with any of the available vaccines against coronavirus 2019 (COVID-19). We describe a case of severe cutaneous leukocytoclastic vasculitis in a patient who had received the ChAdOx1 nCoV-19 Corona Virus Vaccine (Serum Institute of India Pvt. Ltd, COVISHIELD) a recombinant, replication-deficient chimpanzee adenovirus vector encoding the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) spike glycoprotein produced in genetically modified human embryonic kidney 293 cells.

A 60-year-old Indian woman with an unremarkable medical history presented to the internal medicine department with a 5-day history of low-grade fever and skin rash. The patient had received the ChAdOx1 nCoV-19 Corona Virus Vaccine 2 weeks before symptom onset. She had no prior history of allergy or skin eruption and had not recently received any new medication. On examination, she had multiple well-defined erythematous macules and plaques with blisters which were nonblanching of varying sizes. The blood counts, biochemical values, and peripheral smear were normal except for mild elevation in the C-reactive protein (7.5 mg/L [reference value, <6.0]). SARS-CoV-2 RNA was not detected on reverse transcriptase–polymerase chain reaction assay of a sample obtained with a nasopharyngeal swab. A complete listing of the patient's laboratory values including the vasculitic workup is provided in [Table 1]. Biopsies obtained from the skin lesion showed dense perivascular inflammation (mixed inflammatory infiltrate with numerous neutrophils, lymphocytes, and occasional eosinophils) with leukocytoclasia and erythrocyte extravasation. There was fibrinoid necrosis of dermal vessels (with endothelial swelling) as well as of subcutaneous small and medium vessels. The Gram stain, acid-fast bacilli, Wade Fite, and Gomori's methenamine silver stains were negative. Direct immunofluorescence for IgG, IgM, IgA, and complement protein C3 was negative. The clinical presentation, histopathology findings, and recent vaccination history were suggestive of cutaneous leukocytoclastic vasculitis triggered by ChAdOx1 nCoV-19 Corona Virus Vaccine since other systemic causes of leukocytoclastic vasculitis, were excluded by appropriate tests. She was started on 60 mg of oral prednisone (which was tapered over the next 4 weeks and stopped). At a follow-up visit 4 weeks later, examination showed that all of her skin lesions had resolved.
Table 1: Laboratory values including the vasculitic work up

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In a recent study, McMahon et al. found that cutaneous reactions to mRNA COVID-19 vaccines are generally minor and self-limited.[2] The most common cutaneous reactions were delayed large local reactions, local injection site reactions, urticaria, morbilliform rash, and erythromelalgia.[2] The cutaneous adverse effects of the ChAdOx1 nCoV-19 are primarily injection-site reactions.[3] No serious adverse reactions to this vaccine occurred during the trials, and the majority of adverse events reported were mild or moderate in severity, and all were self-limiting.[4] A study with a larger cohort combining four randomized controlled trials in Brazil, South Africa, and the United Kingdom, there was only one case of cellulitis observed with ChAdOx1 nCoV-19.[5] Ad26.CoV2. S (Johnson and Johnson's Janssen vaccine) showed no serious cutaneous adverse effects in trials.[6] A biopsy-proven vasculitis secondary to any of the three main types of COVID-19 vaccines in use globally was not previously described. Our case suggests that vaccine-induced cutaneous reactions could be at times serious.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Cohen SR, Prussick L, Kahn JS, Gao DX, Radfar A, Rosmarin D. Leukocytoclastic vasculitis flare following the COVID-19 vaccine. Int J Dermatol 2021;60:1032-3.  Back to cited text no. 1
    
2.
McMahon DE, Amerson E, Rosenbach M, Lipoff JB, Moustafa D, Tyagi A, et al. Cutaneous reactions reported after Moderna and Pfizer COVID-19 vaccination: A registry-based study of 414 cases. J Am Acad Dermatol 2021;85:46-55.  Back to cited text no. 2
    
3.
Ramasamy MN, Minassian AM, Ewer KJ, Flaxman AL, Folegatti PM, Owens DR, et al. Safety and immunogenicity of ChAdOx1 nCoV-19 vaccine administered in a prime-boost regimen in young and old adults (COV002): A single-blind, randomised, controlled, phase 2/3 trial. Lancet 2021;396:1979-93.  Back to cited text no. 3
    
4.
Folegatti PM, Ewer KJ, Aley PK, Angus B, Becker S, Belij-Rammerstorfer S, et al. Safety and immunogenicity of the ChAdOx1 nCoV-19 vaccine against SARS-CoV-2: A preliminary report of a phase 1/2, single-blind, randomised controlled trial. Lancet 2020;396:467-78.  Back to cited text no. 4
    
5.
Voysey M, Clemens SA, Madhi SA, Weckx LY, Folegatti PM, Aley PK, et al. Safety and efficacy of the ChAdOx1 nCoV-19 vaccine (AZD1222) against SARS-CoV-2: An interim analysis of four randomised controlled trials in Brazil, South Africa, and the UK. Lancet 2021;397:99-111.  Back to cited text no. 5
    
6.
Sadoff J, Gray G, Vandebosch A, Cárdenas V, Shukarev G, Grinsztejn B, et al. Safety and efficacy of single-dose Ad26. COV2. S vaccine against Covid-19. N Engl J Med 2021;384:2187-201.  Back to cited text no. 6
    

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Correspondence Address:
Mansoor C Abdulla,
Department of Medicine, Sultan Qaboos Hospital, P O Box: 98, P. C: 211, Salalah
Oman
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/injms.injms_87_22




 
 
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