key: cord-0765530-tbj0so3r authors: Sandhu, Sunmeet; Bhatnagar, Anuj; Kumar, Harish; Dixit, Prashant Kumar; Paliwal, Gourang; Suhag, Devinder Kumar; Patil, Chetan; Mitra, Debdeep title: Leukocytoclastic vasculitis as a cutaneous manifestation of ChAdOx1 nCoV‐19 corona virus vaccine (recombinant) date: 2021-10-05 journal: Dermatol Ther DOI: 10.1111/dth.15141 sha: 4da6747f09c1d9531523f4b374546bc03c381e7f doc_id: 765530 cord_uid: tbj0so3r With the present COVID‐19 vaccination drive across the world, adverse skin reactions post COVID‐19 vaccine is expected. Majority of these reactions seen were transient or local injection site reactions. However, as the larger population is being vaccinated, certain uncommon dermatological presentations including leukocytoclastic vasculitis, pityriasis rosea, and exacerbation of pre‐existing autoimmune diseases are now being reported. Among all the COVID‐19 vaccines, most of these reactions are seen with messenger ribonucleic acid‐based Pfizer/BioNTech (BNT162b2) and Moderna (mRNA‐1273) vaccine. We report two cases of leukocytoclastic vasculitis following ChAdOx1 nCoV‐19 corona virus vaccine (recombinant) that bring out potential new dermatological manifestations of recombinant corona virus vaccine being administered across the European, South American, and Asian countries. It is important for all health care workers and patients to be aware of the corona virus vaccine associated adverse cutaneous reactions. Various dermatological manifestations of COVID-19 including leukocytoclastic and IgA vasculitis and Kawasaki-like multisystem inflammatory syndrome associated with COVID-19 have been reported. [1] [2] [3] With the ongoing widespread COVID-19 vaccination across all continents, a spectrum of cutaneous reactions are emerging. Majority of these being transient or local injection site reactions. [4] [5] [6] Dermatological manifestations similar to reported in COVID-19 infection are now being increasingly seen associated with COVID-19 vaccination. New onset or reactivation of cutaneous and IgA vasculitis has been observed in handful of cases associated with either messenger ribonucleic acid (mRNA) or inactivated SARS-CoV-2 vaccines but none with ChAdOx1 nCoV-19 corona virus vaccine (recombinant). 4 from a lesion less than 24 h duration was negative. She was managed with oral prednisolone @0.5 mg/kg/day, tapered over 2 weeks with resolution of all symptoms. The patient was advised a repeat titer of anti-spike SARS CoV-2 antibody before the second scheduled dose of vaccine. A 48-year-old hypertensive male, on medication presented with 2 days of fever, myalgia and 1 day of palpable purpura distributed symmetrically over hands, forearms, gluteal region, and lower limbs, Leukocytoclastic vasculitis (LCV) as an adverse event to vaccination particularly to influenza vaccine has been reported. 12 The mechanism of vasculitis is uncertain; however, it may be associated with hypersensitivity or abnormal immunological activation due to trigger of an underlying autoimmune or inflammatory disorder. 12 (Table S1 ). 4, [7] [8] [9] [10] [11] In both of our cases, a temporal association between vaccination and LCV could be established with a probable causal relationship in case 1 and definite relationship in case 2. Historically, first LCV episode in case 2 occurred 7 days after vaccination, which was mild with rash limited to ankles, resolving within a week and without any constitutional symptoms. However, second exposure to vaccine resulted in earlier onset and widespread rash with constitutional symptoms that required oral corticosteroids. This supports the existing data of recurrent and more robust cutaneous reaction on re-exposure to vaccine. 4 A registry-based study of 414 cases who received mRNA COVID-19 vaccine had 38 cases developing cutaneous reaction after first dose, 113 cases after second dose, and 29 cases to both doses. Of these 29 cases, 8 had milder reaction while 13 had more robust reaction on re-exposure but none were serious events, providing reassurance to continue vaccination. 4 Cohen et al. showed fibrin deposition within the small vessel wall which is the hallmark feature of LCV. 8 We observed fibrinoid necrosis in case 2 only. Absence of fibrinoid necrosis in case 1 could be the result of skin biopsy done from the very early phase of LCV when fibrin deposition in the vessel wall was not fully developed. Both the patients were managed with tapering doses of oral prednisolone. There is apprehension regarding use of immunosuppressants soon after vaccine. A dose-dependent variable effect on immunity has been reported with corticosteroids with adequate seroprotection with doses <20 mg/day. It is contemplated that systemic corticosteroids have "no or minimal risk" to patients' immune response irrespective of type of COVID-19 vaccine. 14 Health care providers must be aware of the cutaneous manifestations of COVID-19 vaccine as it can potentially precipitate or exacerbate cutaneous inflammation. This is equally important while reassuring general population to continue vaccination if cutaneous reactions are not severe enough to discontinue vaccination, as potential benefits of COVID-19 vaccine are far more in this pandemic. Therapeutic options in such cases or events will depend on case-to-case basis in the best interest of each and every patient. We are thankful to our patient for her support and cooperation. There are no conflicts of interest. The manuscript has been read and approved by all the authors. The requirements for authorship as stated earlier in this document have been met, and each author believes that the manuscript represents honest work. The authors certify that they have obtained all appropriate patient consent forms for use of patient photographs and data obtained. We confirm that the manuscript has been read and approved by all the authors, that the requirements for authorship as stated earlier in this document have been met and that each author believes that the manuscript represents honest work. The data that support the findings of this study are available from the corresponding author upon reasonable request. https://orcid.org/0000-0002-9222-4006 Additional supporting information may be found in the online version of the article at the publisher's website. 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