Correspondence Address:
Preema Sinha
Department of Dermatology, Base Hospital, Lucknow, Uttar Pradesh
India

Full Text



Sir,

An 18-year-old girl with no other previous known comorbidities presented with mild to moderate grade fever of 2 days duration. The onset of fever was following vaccination against COVID-19 with ChAdOx1 nCoV-19 coronavirus (recombinant) vaccine. There were no associated chills, rigor, sore throat, burning micturition, or loose stools. A day after the onset of fever, the patient developed mildly itchy red fluid-filled lesions distributed over her limbs and trunk. There was no history of atopy in the past.

On examination, the patient had normal vitals, and the systemic examination was essentially normal. Dermatological examination revealed symmetrical erythematous papulovesicular rash over all four limbs, predominantly involving the extensor surfaces and the trunk [Figure 1] and [Figure 2]. All mucosae were normal. There was no lymphadenopathy, hepatosplenomegaly, or joint involvement.{Figure 1}{Figure 2}

On investigation, complete blood count and renal and liver function tests were within normal range, and urinalysis was normal. The hepatitis B antigen test was negative. Tzanck smear from the vesicular lesion did not show any acantholysis or multinucleated giant cells.

A skin biopsy was done from a lesion on her left forearm, which revealed an epidermis with mild to moderate spongiosis associated with a dense perivascular lymphomononuclear cellular infiltrate in the upper dermis [Figure 3] and [Figure 4]. Based on the clinical presentation and the biopsy report, a diagnosis of likely vaccine-triggered papulovesicular lesion likely Gianotti–Crosti-like eruption was made. She was provided with symptomatic care in the form of topical corticosteroids, calamine lotion, and antihistaminics. She responded well to the above treatment with regression of lesions in the next 3 weeks.{Figure 3}{Figure 4}

Gianotti–Crosti syndrome, also known as papular acrodermatitis, is a dermatosis most commonly seen in children in the age group of 1 to 6 years but rarely reported in adolescents and adults.[1] It does not show any racial or gender predilection. It is characterized by papular or vesiculopapular eruptions symmetrically distributed over extensors of limbs, trunk, cheeks, buttocks, and palms and soles. The lesions may be mild to moderately itchy. The lesions may occasionally also show vesiculation or may be purpuric.[1],[2] Fever, lymphadenitis, and other symptoms such as hepatosplenomegaly or pharyngitis may be seen in association with the rash or preceding it. Mucosae are characteristically spared. The syndrome is self-limiting with the lesions completely resolving in usually 2 weeks to 2 months duration. However, symptomatic and supportive treatment is provided to hasten the resolution of the lesions.

Gianotti–Crosti syndrome is known to be triggered by viral infections, especially hepatitis B and Epstein–Barr virus (EBV).[2] It is also triggered by vaccination: diphtheria, pertussis, and tetanus (DPT) vaccine. Other vaccines implicated are influenza and the measles, mumps, and rubella (MMR) vaccine.[1],[2]

The pathomechanism of papular acrodermatitis is mostly unknown. Two mechanisms are speculated; firstly, an IgE-mediated mechanism as it is commonly seen in atopic individuals and secondly a delayed type of hypersensitivity. Complications include postinflammatory hypopigmentation or hyperpigmentation which may occur, especially in darker skin phenotypes and persist for up to 6 months.[1],[2]

Since the beginning of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, several case reports of vesicular lesions in patients with COVID-19 during the course of their illness have been reported.[3],[4],[5],[6]

Report by Marzano et al.[4] mentions vesicular and chickenpox-like exanthem as cutaneous manifestations in patients with COVID-19.

Brin et al. and Swali et al. described cases of Gianotti–Crosti-like rash in COVID-19 patients.[3],[6]

However, we cannot categorically affirm that these lesions are directly or indirectly caused by the vaccine against SARS-CoV-2. More studies are needed to elucidate this point.

But this presentation is of particular interest because it shows that the vaccine is triggering a similar immune response as can be seen after the virus as many case reports mention vesicular lesions as a cutaneous manifestation of SARS-CoV-2 infection.[3],[4],[5],[6] Post vaccine similar vesicular rash shows that the body is mounting an immune response to the vaccine.

This case report is an attempt on the author's part to elucidate and increase the awareness of practicing physicians about this triggered condition that occurred postvaccination.

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.

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