key: cord-0782644-p4ddnc53
authors: Alshammari, Fouad; Alzomia, Mohammed; Korairi, Abdulrahman; Alajlan, Mohammed; Abuzied, Yacoub; AlSheef, Mohammed
title: Bullous pemphigoid after second dose of mRNA- (Pfizer-BioNTech) Covid-19 vaccine: A case report
date: 2022-03-01
journal: Ann Med Surg (Lond)
DOI: 10.1016/j.amsu.2022.103420
sha: cd383eb1378ffdd24509ebcdd56af8a86d8a2b92
doc_id: 782644
cord_uid: p4ddnc53

INTRODUCTION: and importance: Messenger RNA vaccines, commonly known as mRNA vaccines, are the first COVID-19 vaccines that have been authorized and licensed in the United States. Two mRNA vaccines, BNT162b2 (Pfizer-BioNTech) and mRNA-1273 (Moderna) are available. Mass vaccination remains the most critical way to halt the spread of the COVID pandemic. The most common adverse effects of the COVID vaccines are headache, muscular soreness, weariness, redness, swelling, and tenderness at the injection site. The dermatological adverse effects of mRNA vaccines, on the other hand, are little understood. We present a case of bullous fixed medication eruption following delivery of the second dose of Pfizer's Covid-19 vaccination. CASE PRESENTATION: We discuss the case of a 78-year-old man who went to the Emergency Department at King Fahad Medical City in Riyadh, Saudi Arabia, with numerous bullae throughout his extremities one day after receiving the second dosage of Pfizer Covid-19 vaccine. The bullae began three days before his presentation, and they were preceded by intense pruritus and urticated plaques. A skin biopsy was performed which revealed IgG (+1), IgM (+1), and C3 (+1) staining of the basement membrane. Another punch skin biopsy taken from an intact bulla was suboptimal compressing of dermal tissue only, revealing modest perivascular lymphocytic infiltrative and scattered eosinophils. This pathological picture with superficial perivascular inflammatory dermatitis, and the presence of eosinophils suggests drug-induced bullous pemphigoid. The patient was treated with topical and systemic corticosteroids, fusidic acid cream, and emollients after a confirmed diagnosis of bullous pemphigoid was obtained. He was hospitalized for 3 weeks as a case of severe sepsis due to a skin infection, and he was started initially on empiric antibiotics with piperacillin-tazobactam plus vancomycin that was later upgraded to meropenem and vancomycin based on the results of the blood and wound cultures. The patient suffered a pulmonary embolism on the second day of hospitalization and was placed on a heparin infusion that could potentially contribute to his death one month after discharge from our hospital. CLINICAL DISCUSSION: Bullous pemphigoid is the most frequent autoimmune bullous disease. It occurs in the elderly. The cause of this disease is unknown, although it sometimes can be triggered by taking certain medications. Two case reports have also revealed bullous pemphigoid eruption following immunization. One case report reported a 78-year-old lady with diabetes and Alzheimer's disease who developed tense bullae on her face and torso after getting the second dosage of the Pfizer-BioNTech COVID-19 Vaccine. Another case study described a 77-year-old male patient who developed generalized pruritis and bullae on erythematous bases one day after receiving the AstraZeneca COVID-19 vaccination. This new-onset bullous pemphigoid phenomenon has also been observed with other vaccinations such as rabies and swine flu. CONCLUSION: Although uncommon, several dermatological side reactions like bullous eruptions have been reported following the mRNA Pfizer Covid-19 vaccination. According to this case report, Bullous pemphigoid might be caused by the mRNA- (Pfizer) Covid-19 Vaccine.

Case presentation: We discuss the case of a 78-year-old man who went to the Emergency Department at King Fahad Medical City in Riyadh, Saudi Arabia, with numerous bullae throughout his extremities one day after receiving the second dosage of Pfizer Covid-19 vaccine. The bullae began three days before his presentation, and they were preceded by intense pruritus and urticated plaques. A skin biopsy was performed which revealed IgG (+1), IgM (+1), and C3 (+1) staining of the basement membrane. Another punch skin biopsy taken from an intact bulla was suboptimal compressing of dermal tissue only, revealing modest perivascular lymphocytic infiltrative and scattered eosinophils. This pathological picture with superficial perivascular inflammatory dermatitis, and the presence of eosinophils suggests drug-induced bullous pemphigoid. The patient was treated with topical and systemic corticosteroids, fusidic acid cream, and emollients after a confirmed diagnosis of bullous pemphigoid was obtained. He was hospitalized for 3 weeks as a case of severe sepsis due to a skin infection, and he was started initially on empiric antibiotics with piperacillin-tazobactam plus vancomycin that was later upgraded to meropenem and vancomycin J o u r n a l P r e -p r o o f based on the results of the blood and wound cultures. The patient suffered a pulmonary embolism on the second day of hospitalization and was placed on a heparin infusion that could potentially contribute to his death one month after discharge from our hospital.

Clinical discussion: Bullous pemphigoid is the most frequent autoimmune bullous disease. It occurs in the elderly. The cause of this disease is unknown, although it sometimes can be triggered by taking certain medications. Two case reports have also revealed bullous pemphigoid eruption following immunization. One case report reported a 78-year-old lady with diabetes and Alzheimer's disease who developed tense bullae on her face and torso after getting the second dosage of the Pfizer-BioNTech COVID-19 Vaccine. Another case study described a 77-year-old male patient who developed generalized pruritis and bullae on erythematous bases one day after receiving the AstraZeneca COVID-19 vaccination. This new-onset bullous pemphigoid phenomenon has also been observed with other vaccinations such as rabies and swine flu. 

The patient was hypotensive, tachypneic, tachycardic, and febrile (38 degrees Celsius). He was given 2L of standard intravenous saline as well as additional oxygen. On physical examination, there were numerous diffuse erosions, post-inflammatory hyper and hypopigmentation, and crustation.

There were no new blisters or original skin lesions discovered. A laboratory examination revealed a white blood count of 17.2 with a neutrophilic preponderance. He was hospitalized as a case of severe sepsis due to a skin infection, and he began empiric treatment with piperacillin-tazobactam plus vancomycin. Blood and wound cultures grew extended-spectrum beta-lactamase Escherichia coli and Methicillin-resistant Staphylococcus aureus (MRSA), respectively, according to the septic workup. As a result, antibiotics were increased to meropenem and vancomycin. The patient suffered a pulmonary embolism on the second day of hospitalization and was placed on a heparin infusion.

He was admitted to the hospital for three weeks to finish the necessary course of antibiotics. He was discharged home after 25 days of prednisolone 20mg daily treatment with a spectacular clinical response, as seen in the statistics (4). Then after one month from discharge patient was found to have died in his bed of an unknown cause but it could be attributed to pulmonary embolism. 

Bullous pemphigoid is a rare autoimmune dermatological disorder that primarily affects the elderly beyond the age of 60. The cause of this disease is unknown, although it sometimes can be triggered by taking certain medications. Itching is frequently the first symptom, followed by urticarial lesions and, finally, blisters. Numerous cutaneous abnormalities, most typically local site injection responses, have been described with mRNA COVID-19 vaccinations. [4] Morbilliform eruption, urticaria, Pernio-like lesions, and vasculitis are some uncommon cutaneous symptoms that have been reported too. [6] Two case reports have also revealed bullous pemphigoid eruption following immunization. One case report reported a 78-year-old lady with diabetes and Alzheimer's disease who developed tense bullae on her face and torso after getting the second dosage of the Pfizer-BioNTech COVID-19 Vaccine [7] Another case study described a 77-year-old male patient who developed generalized pruritis and bullae on erythematous bases one day after receiving the AstraZeneca COVID-19 vaccination. [8] This new-onset bullous pemphigoid phenomenon has also been observed with other vaccinations such as rabies and swine flu. [9, 10] COVID-19 patients may also have cutaneous symptoms. Morbilliform rash, pernio-like acral lesions, urticaria, macular erythema, vesicular eruption, papulosquamous eruption, and retiform purpura were the most often reported signs in a 716-patient worldwide registry. [11] Other autoimmune problems have been observed following the injection of COVID-19 vaccinations. For example, vaccine-associated immune thrombosis and thrombocytopenia (VITT) is now a well-known adverse effect of the COVID-19 vaccine, especially the AstraZeneca vaccine. [12] Guillain-Barré syndrome (GBS) is another autoimmune disorder that has been linked to an unfavorable event. [13] COVID-19 patients may also have other non-cutaneous autoimmune problems such as hemophagocytic J o u r n a l P r e -p r o o f syndrome, Kawasaki disease in children and adults, myositis, arthritis, myocarditis, neurological and renal immune-related manifestations. [14] Conclusion -Bullous pemphigoid is the most frequent autoimmune bullous disease. It occurs in the elderly. The cause of this disease is unknown, although it sometimes can be triggered by taking certain medications and vaccines. According to this case report, Bullous pemphigoid might be caused by the mRNA-(Pfizer) Covid-19 Vaccine. Additional case reports are required to learn more about this disease to achieve early diagnosis and initiation of prompt therapy. 

COVID-19: A Multidisciplinary Review

COVID-19 vaccines: The status and perspectives in delivery points of view

COVID-19 Vaccines: Current Understanding on Immunogenicity, Safety, and Further Considerations

Vaccine side-effects and SARS-CoV-2 infection after vaccination in users of the COVID Symptom Study app in the UK: a prospective observational study

The SCARE 2020 Guideline: Updating Consensus Surgical CAse REport (SCARE) Guidelines

Cutaneous reactions reported after Moderna and Pfizer COVID-19 vaccination: A registry-based study of 414 cases

Bullous pemphigoid and COVID-19 vaccine

Bullous pemphigoid induced by the AstraZeneca COVID-19 vaccine

Bullous pemphigoid triggered by rabies vaccine

Bullous pemphigoid triggered by swine flu vaccination: case report and review of vaccine triggered pemphigoid

The spectrum of COVID-19-associated dermatologic manifestations: An international registry of 716 patients from 31 countries

COVID-19 vaccine-associated immune thrombosis and thrombocytopenia (VITT): Diagnostic and therapeutic recommendations for a new syndrome

Guillain-Barre syndrome after vaccination for Covid-19. The first report in Latin America

Systemic and organ-specific immune-related manifestations of COVID-19

The authors would like to thank the research center at King Fahad Medical City in Riyadh, Saudi Arabia, for their assistance and technical support.We are thankful to Dr. Mohammed Ameen (Pathology Consultant at King Fahad Medical City) for his kind assistance and cooperation in collecting the patient's pathology figures.

Not commissioned, externally peer-reviewed.J o u r n a l P r e -p r o o f