key: cord-0821130-lmnl4xev authors: Sowell, Josiah; Bevans, Stephanie L.; Elston, Carly A. title: Widespread cutaneous reaction to the Johnson & Johnson Ad26.COV2.S vaccine date: 2021-11-03 journal: JAAD Case Rep DOI: 10.1016/j.jdcr.2021.08.037 sha: 6b50dcb6e5d1fdd0e80e911208932070e4a19031 doc_id: 821130 cord_uid: lmnl4xev nan To the Editor: We read with interest the report of the cutaneous eruption to Janssen Ad26.COV2.S vaccine by Nutan et al Q3 . We report another such reaction with slightly different clinical features, presenting with a largely cutaneous component. The Janssen Ad26.COV2.S vaccine against COVID-19 represents the first single-dose option used in prevention of infection. It employs a viral vector using modified adenovirus DNA to produce the SARS-CoV-2 spike protein to illicit an immune response and has proven 66% effective in preventing COVID-19 infection. [1] [2] [3] Only one severe hypersensitivity reaction and no anaphylactic reactions were reported during the safety and efficacy trials. 2,3 On April 12, 2021, the Janssen Ad26.COV2.S vaccine distribution was temporarily suspended due to a rare side effect of cerebral venous sinus thrombosis combined with thrombocytopenia with antibodies to platelet factor 4; however, the vaccine distribution was resumed on April 23, 2021. 4 We report a case of a diffuse erythematous dermatitis developing in a patient who received the Janssen Ad26.COV2.S vaccine. An 80-year-old woman with a history of factor V Leiden, hypertension, hyperlipidemia, and chronic thrombocytopenia presented to the emergency department with febrile episodes and diffusely scattered, pruritic, erythematous-to-violaceous edematous plaques involving the entire cutaneous surface with shallow erosions of posterior oropharynx and mucosal lips (Fig 1 Q4 ). Punch biopsy revealed spongiotic and interface dermatitis with superficial and deep lymphocytic infiltrate consistent with a drug eruption or viral exanthem. Laboratory evaluation at the time of presentation was remarkable only for thrombocytopenia and mild anemia. Extensive workup included chest X-ray, computed tomography of the abdomen and pelvis, throat culture, anti-streptolysin O, blood cultures, urinalysis, SARS-CoV-2 PCR Q5 , HIV1/2 antigen and antibodies, hepatitis C antibodies, viral respiratory panel, influenza A and B virus PCR, parvovirus IgG and Immunoglobulin M antibodies, antinuclear antibodies, anti-Smith antibodies, anti-double-stranded DNA antibodies, and C3 and C4, which were all normal. The patient underwent workup for her chronic thrombocytopenia with no evidence of overt malignancy. Bone marrow biopsy revealed normocellular marrow with trilineage hematopoiesis, and flow cytometry was negative for a clonal lymphoid or aberrant myeloid population. Increased numbers of macrophages with focal hemophagocytosis were noted on bone marrow biopsy. However, serum ferritin concentration was 273 ng/mL, and the patient did not meet the criteria for hemophagocytic syndrome. The patient denied any new medications ( prescription or over the counter) or recent medication changes but reported receiving the Janssen Ad26.COV2.S vaccination 3 days prior to the development of her rash. She was treated with topical triamcinolone ointment, antihistamines (cetirizine 10 mg daily), and prednisone 20 mg daily with resolution of her eruption. Although a direct causal relationship between the cutaneous eruption observed in our patient and the vaccination cannot be confirmed, extensive workup and thorough medication history revealed no other underlying cause. Our patient's dermatitis proved nonlife-threatening, and improvement was achieved with oral prednisone, antihistamines, and topical steroids. Our case suggests a possible association of the Janssen Ad26.COV2.S vaccination with a nonlifethreatening, diffuse cutaneous eruption. We are 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 Centers for Disease Control and Prevention. Johnson & Johnson's Janssen COVID-19 vaccine Q8 overview and safety The Johnson & Johnson vaccine for COVID-19 FDA Briefing Document Janssen Ad26.-COV2.S Q9 vaccine for the prevention of COVID-19 Allergic reactions including anaphylaxis after receipt of the first dose of Moderna COVID-19 vaccine -United States A case of severe cutaneous adverse reaction following administration of the Janssen Ad26.COV2.S COVID-19 vaccine