key: cord-0031615-2pyf2s5u
authors: Nguyen, Tam H.; Gabros, Sarah; Friefeld, Sean; Gupta, Akhil; Skopit, Stanley
title: Generalized Granuloma Annulare after COVID-19 vaccination
date: 2022-05-14
journal: JAAD Case Rep
DOI: 10.1016/j.jdcr.2022.05.003
sha: 223a2217da5a85017b333766d60a316a7bc8673f
doc_id: 31615
cord_uid: 2pyf2s5u

nan

However, it is postulated to be a hypersensitivity reaction to a trigger like trauma, medications, 49 malignancy, viral infections and, vaccinations, with some forms associated with diabetes mellitus 50 and dyslipidemia. 1, 2, 3 In early 2021, authors described the first case of generalized GA associated 51 with pneumococcal vaccination less than two weeks after a patient received the conjugate 52 vaccine (PCV13). 2 Although the patient was asymptomatic and the disease self-limited, the exact 53 pathogenesis of this disease process remains unknown. The etiology of GA is unknown, but is postulated to be a delayed type hypersensitivity to 94 a stimulus. 1, 4, 5 There have been several associations with generalized GA including DM, 95 malignancy, thyroid disease, dyslipidemia, HIV and Hepatitis B and C. Generalized GA has a 96 prolonged course that is poorly responsive to treatment and comprises 8-15% of all cases. 5 Although granuloma annulare is considered a benign disease, it can cause patients 124 significant distress especially in generalized cases. Our patient has a history of hyperlipidemia, 125 which, along with diabetes, has been cited as a likely risk factor for granuloma annulare, 126 however more studies are needed to better substantiate this relationship. 3, 4 No studies have 127 evaluated the time sequence between dyslipidemia and onset of generalized granuloma annulare. 128 This was considered as a possible etiology; however, given her ten year history of 129 hyperlipidemia and treatment with a statin, we concluded that the presentation of generalized GA 130 two weeks after COVID-19 vaccination was more likely attributed to this as opposed to 131 hyperlipidemia. It is important to acknowledge that because the majority of cases of granuloma 132 annulare are idiopathic, the onset of generalized disease in our patient after the COVID-19 133 vaccine could simply be a temporal coincidence. That being said, the patient's flare after the 134 booster dose does provide more evidence to support the vaccine as a contributor. 135

The nebulous nature of GA's etiology is likely the culprit reason for our patient not 136 experiencing generalized GA after her first dose of the vaccine. It is also possible that threshold 137 J o u r n a l P r e -p r o o f titers of a stimulatory antigen were not present until after the second vaccine dose or that 138 immunologic memory was naïve until the second dose; initial testing of the Pfizer and Moderna 139 vaccines showed that a relatively weak immune response was elicited after the first dose, 140 followed by a more robust response when the second dose was given. 10 

Benign melanocytic neoplasms

Generalized 209 granuloma annulare after pneumococcal vaccination. An Bras Dermatol

Association of Granuloma 212

Annulare With Type 2 Diabetes, Hyperlipidemia, Autoimmune Disorders

Hematologic Malignant Neoplasms

Successful Treatment of 218

Generalized Granuloma Annulare with Pentoxifylline

Granuloma annulare triggered by SARS-CoV-2 infection

Immunohistochemical staining

Covid-19 vaccine and autoimmunity: 225 Awakening the sleeping dragon

Potential antigenic cross-reactivity between SARS-CoV-2 and 228 human tissue with a possible link to an increase in autoimmune diseases

Do COVID-19 RNA-based vaccines put at risk of immune-mediated diseases

In reply to "potential antigenic cross-reactivity between SARS-CoV-2 and human tissue 232 with a possible link to an increase in autoimmune diseases

Livingston EH. Necessity of 2 Doses of the Pfizer and Moderna COVID-19 Vaccines

Granuloma Annulare: GA 160 161Coronavirus disease of 2019: COVID-19 162 163Severe acute respiratory syndrome coronavirus 2: SARS-CoV-2 164 165Pneumococcal conjugate vaccine: PCV-13  166  167  168  169  170  171  172  173  174  175  176  177  178  179  180  181  182  183  184  185  186  187  188  189  190  191  192  193  194  195  196  197  198  199  200  201  202