Cutaneous lymphocytic vasculitis after administration of COVID‐19 mRNA vaccine

Abstract

Dear Editor, To date, several individuals have received COVID-19 vaccinations; therefore, the development of adverse skin reactions is expected. We report a peculiar cutaneous eruption post anti-Covid-19 vaccination (BNT162B2/ Pfizer) in a woman without comorbidities, with a previous history of Covid 19 infection. A 51-year-old female patient, in good general health, had a symptomatic Covid-19 infection in April 2020 with fever, arthralgia, loss of taste and smell for 3 months and peripheral leg neuropathy that lasted for a few days; at this time, she did not present any skin manifestation. The initial anti-spike antibody value was 70.2 AU/ml (n.v. AU <12 ml). In early January 2021, 6 h after the first dose anti-Covid-19 vaccination (BNT162B2/Pfizer), she presented edema and pain at the injection site and, the next day, arthralgia, fever, and the appearance of an itchy maculopapular rash. Initially, the eruption was localized on the upper limbs (volar surface) (Figure 1A), retro-auricular region and, 1-day later, on the trunk. Anti-spike antibody value at this time was >400 AU/ml and neutralizing antibodies titer was 1:640. Nasal swab proved negative for Sars-Cov-2 virus. Two skin biopsies for histological examination and direct immunofluorescence were done. By histology, a lymphocytic vasculitis with lymphocytes infiltrating the wall of small dermal vessels, with endothelial swelling was noticed (Figure 1B) in absence of thrombi. A predominance of T CD4+ lymphocytes (Dako) over T CD8+ cells (Dako) was noticed (Figure 1C,D); immunostaining with anti-SARS-CoV-2 nucleocapsid protein antibody (Sino Biological) did not show any specific reactivity. Direct immunofluorescence directed to IgG, IgM, IgA fibrinogen, and C3 (Dako, Denmark) did not reveal any deposits in the vessels. Further blood analyses to exclude concomitant viral reactivations (in particular HHV-6-DNA, HHV-7-DNA, EBV-DNA, and CMV-DNA) proved negative; parvovirus IgG and IgM were absent. Therapy with systemic antihistamine and local steroid led to the resolution of the manifestations within a week. Due to the high level of immunization demonstrated by the serological test, the second dose of vaccine was not carried out. Vaccination in previously infected subjects is still debated as an opportunity to strengthen the defenses against the virus; however, the