key: cord-0699842-71a6lf93
authors: Shrestha, Prinsa; Bhattarai, Suraj; Dhungana, Jaya; Bhattarai, Tulsi
title: Delayed-onset Anaphylaxis After mRNA-Based COVID-19 Vaccination in an Adolescent Male
date: 2022-05-06
journal: Pediatr Infect Dis J
DOI: 10.1097/inf.0000000000003506
sha: 6924504c99f37ea74e28f9cfab475948e4199ae5
doc_id: 699842
cord_uid: 71a6lf93

nan

A dverse events after mRNA-based COVID-19 vaccinations have been reported in the adolescents. [1] [2] [3] We report a case of 16-year-old male who developed anaphylaxis 27 hours after the first dose of BNT162b2 COVID-19 vaccine, and improved with 2 doses of intramuscular adrenaline 1 mg (1:1000).

A 16-year-old male presented to the emergency department 31 hours after receiving the first dose of BNT162b2 (Pfizer-BioNTech) COVID-19 vaccine (Batch No. PAA173696) on January 11, 2022. He had 2 episodes of vomiting that started 6 hours postvaccination and 3 episodes of loose stools without mucus or blood. He developed body rash after 27 hours of vaccination associated with pruritus. He also complained acute chest tightness and shortness of breath for 1 hour, present even at rest. On examination, he was ill-looking, with red eyes, upper lip swelling, and diffuse erythematous rash over anterior abdominal wall, back, and bilateral upper limbs. He was febrile and vitals were unstable (pulse rate 140 beats per minute, respiratory rate 24 per minute, blood pressure 90/60 mm Hg), with oxygen saturation of 84% in room air. On chest auscultation, there was bilateral decreased air entry with no added sounds. Other systemic examinations were normal.

The patient denied recent insect bite, application of new cosmetic agent, or intake of new food items or medicines between vaccination and symptoms onset. He had no known allergy to any drugs, food, pets, insect stings, dust, pollens, or vaccinations.

He did not have history of asthma, atopy, or chronic illness; no previous exposure to bowel preparations or laxatives either. He had never been infected with COVID-19. His laboratory reports were mostly normal except high d-dimer (5.08 mg per liter) (see Table, Supplemental Digital Content 1, http://links.lww.com/INF/E690).

In the emergency room, the patient was treated with oxygen supplementation via nasal prongs and intravenous medications: hydrocortisone 200 mg, pheniramine maleate 90 mg, ranitidine 50 mg, hyoscine butyl bromide 20 mg, ketorolac 30 mg, pantoprazole 40 mg, and normal saline infusion 500 mL. He improved initially, but worsened after few hours. Then he was treated with 2 doses of intramuscular adrenaline 1 mg (1:1000), after which his condition improved. The same day, he was shifted to the intensive care unit for further management. The patient was discharged after 4 days of hospitalization, and, as of February 10, 2022, he is doing fine. This incident has been reported to the Ministry of Health and Population.

Nepal deployed COVID-19 vaccination on January 27, 2021, starting with Oxford-AstraZeneca (Covishield) vaccination for adults and elderly. 4 The mRNAbased vaccines were introduced in late 2021, for children 12-17 years (www.covid19. mohp.gov.np). However, there are no official publications regarding COVID-19 vaccination associated adverse events following immunization (AEFI). Latest global reports suggest anaphylaxis incidence closer to 1:200,000 doses with respect to BNT162b2. 1 In most anaphylactic reactions, symptoms begin within minutes (generally 30 minutes) of exposure to the allergen. 5 In case of vaccines, symptoms onset is 13 minutes on average, and generally, 86% occur within 30 minutes of vaccination. 3 Symptoms can range from cutaneous symptoms to respiratory distress and cardiovascular collapse. 5 Delayed reactions which occur hours to days after exposure, typically manifest as cutaneous reaction. 5 

COVID-19 vaccine-associated anaphylaxis: a statement of the World Allergy Organization Anaphylaxis Committee

Population-based incidence of myopericarditis after COVID-19 vaccination in Danish adolescents

Allergic reactions including anaphylaxis after receipt of the first dose of Pfizer-BioNTech COVID-19 vaccine

A million-dose success for Nepal: insights from Nepal's national vaccine deployment plan against COVID-19

Anaphylaxis to vaccinations: a review of the literature and evaluation of the COVID-19 mRNA vaccinations