key: cord-0763072-keqxhvdz
authors: Chopra, Shara; Kim, Yesul; Flamm, Alexandra
title: Cutaneous Skin Manifestation following mRNA Moderna SARS-CoV-2 Vaccine with Dermal Hypersensitivity Reaction Histopathology
date: 2021-08-14
journal: JAAD Case Rep
DOI: 10.1016/j.jdcr.2021.07.039
sha: 6fed01dc5b4fea7798b3188f54fef614e44d1a3b
doc_id: 763072
cord_uid: keqxhvdz

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clinical scenarios, including bite reactions, urticarial dermatitis and vasculitis, drug eruptions, 26 and eczematous dermatitis. DHR is described as a perivascular, lymphocytic infiltrate with 27 eosinophils involving the papillary and upper reticular dermis and sometimes minimally the 28 epidermis and has been very rarely reported to vaccination. 1,2 Therefore, we read with great 29 interest the case series by Sidlow et al describing a generalized urticarial and a morbilliform 30 eruption in the setting of SARS-CoV-2 vaccination, 3 similar to a case seen at our institution as 31 described below. 32 33 A 56-year-old female health care worker presented nine days following her first dose of the 34

Moderna SARS-CoV-2 vaccine in her left arm with an intensely pruritic rash that started on the 35 left hand and spread to the left elbow, both hands, and both feet. Two days of a prednisone taper 36 (40mg daily for two days, 20mg daily for two days, 10mg for one day) from her primary care 37 physician slightly improved the pruritus. She had a dusky violaceous papule on one of her left 38 pinky fingers, edematous, violaceous papules on the palms of the hands, and urticarial lesions on 39 the dorsum of hands, elbows, and upper thighs ( Figure 1A and 1B). She reported occasional 40 chills one day after the vaccine but denied any recent illnesses, new medications, or outdoor 41 exposures. Our differential diagnosis included erythema multiforme, neutrophilic eccrine 42 hidradenitis, pernio, a vasculopathic etiology, or other viral etiology. A four-millimeter punch 43 biopsy was performed of an edematous dusky pink papule of the right dorsal foot ( Figure 1C) . 44

Histopathological examination demonstrated an area of ulceration and an underlying perivascular 45 and periadnexal mixed inflammatory infiltrate with lymphocytes and scattered eosinophils within the superficial, mid, and deep dermis, consistent with a traumatized DHR (Figure 2) . We 47 advised her to use triamcinolone 0.1% cream twice daily and complete the prednisone taper. At 48 her one-month follow-up, she reported a few flares of the pruritic rash on her hands and feet off 49 the prednisone. While similar to the initial presentation, the rash was controlled with the 50 triamcinolone cream and improved overall. She was instructed to contact us for any worsening or 51 flaring of her symptoms and has not required re-evaluation as of four months after the visit. She 

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