key: cord-0735718-jnhdr1uc
authors: Matthews, Natalie H.; Pichan, Cayla M.; Hristov, Alexandra C.; Markovitz, David M.; Darland, Allison M.
title: Response to Berry et al’s “Cutaneous small-vessel vasculitis following single-dose Janssen Ad26.COV2.S vaccination”
date: 2022-01-21
journal: JAAD Case Rep
DOI: 10.1016/j.jdcr.2021.08.041
sha: 85e6b8da27fdedf34d97764e94adabf6e5f637a3
doc_id: 735718
cord_uid: jnhdr1uc

nan

Response to Berry et al's ''Cutaneous small-vessel vasculitis following single-dose Janssen Ad26.COV2.S vaccination'' Q1 To the Editor Q2 : On February 27, 2021, the United States Food and Drug Administration issued an Emergency Use Authorization for the Janssen adenovirus vector COVID-19 vaccine. [1] [2] The most commonly reported adverse events of the Janssen vaccine include mild reactogenicity symptoms, including location injection site reactions, hypersensitivity, and systemic reactogenicity, like fatigue and headache. 2 Prior vaccines, including adenovirus vector vaccines and influenza, have reported small-and medium-vessel vasculitis as potential adverse events. [3] [4] [5] Most recently, Berry et al reported a case of cutaneous small-vessel vasculitis following the Janssen COVID-19 vaccine. Here, we present a similar case of cutaneous small-vessel vasculitis following vaccination with the Janssen COVID-19 vaccine.

A 64-year-old man with a previous history of deep vein thrombosis of his left lower extremity presented with a worsening rash for 4 days. His rash initially presented on his feet bilaterally as palpable purpuric papules and plaques, which spread up his legs and thighs, with the newest lesions distributed over his arms, abdomen, buttocks, and back (Fig 1) . The lesions were tender to palpation and were more pronounced, edematous, and tender on the left leg compared with the right. Ten days before rash onset, the patient received his Johnson & Johnson (Janssen) COVID-19 vaccine. He denied any complications with previous vaccines, including influenza vaccines.

The patient was afebrile. His review of systems was otherwise negative. The only medication he took was warfarin, and he denied any new or changes in supplements or medications. The patient denied a history of autoimmune disease or recent infections. He was up to date on age-appropriate cancer screenings. Connective tissue and autoimmune laboratory workup were negative, including antinuclear antibody, anti-double-stranded DNA, perinuclear and cytoplasmic antineutrophil cytoplasmic antibodies, rheumatoid factor, and extractable nuclear antigen panel, and complement C3 and C4 level testing was within normal limits. Hepatitis panel and HIV antigen-antibody testing were nonreactive. Hematologic, renal, and hepatic functions were within normal limits.

Biopsy from the patient's thigh revealed fibrinoid necrosis of vessel walls with fibrin thrombi, extravasated erythrocytes, and neutrophilic inflammatory infiltrate with leukocytoclasia (Fig 2) . Direct immunofluorescence microscopy of a biopsied specimen from a new lesion on the abdomen was negative for specific immune deposits. SARS-CoV-2 in situ hybridization was negative. The diagnosis of leukocytoclastic vasculitis was rendered. Initiation 1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55 of high-dose corticosteroids led to the rapid improvement of the patient's cutaneous symptoms and clinical appearance of the rash. The patient's vasculitis resolved and remained quiescent after the completion of his oral steroid course. His lower extremity function has returned to baseline, and there is post-inflammatory hyperpigmentation at sites of previously involved leukocytoclastic vasculitis, which are gradually improving in clinical appearance.

The temporal association between the patient's vaccination and subsequent development of vasculitis in the absence of other possible inciting etiologies suggests that the vaccine may have been the trigger; however, we cannot ascribe causation. While there have been cases of systemic illness in the setting of cutaneous vasculitis, 3,4 our patient was not acutely ill and responded rapidly to appropriate treatment. 111  112  113  114  115  116  117  118  119  120  121  122  123  124  125  126  127  128  129  130  131  132  133  134  135  136  137  138  139  140  141  142  143  144  145  146  147  148  149  150  151  152  153  154  155  156  157  158  159  160  161  162  163  164  165   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  203  204  205  206  207  208  209  210  211  212  213  214  215  216  217  218  219  220 

Interim results of a phase 1-2a trial of Ad26.COV2.S COVID-19 vaccine

The Advisory Committee on Immunization Practices' interim recommendation for the use of Janssen COVID-19 vaccine -United States

Leucocytoclastic vasculitis following influenza vaccination

Vasculitis following influenza vaccination: a review of the literature

Single-cycle adenovirus vectors in the current vaccine landscape

None disclosed.