key: cord-0843609-8pnf6zd1
authors: Strahan, Alexis; Ali, Rowanne; Freeman, Esther
title: Chronic Spontaneous Urticaria after COVID-19 primary vaccine series and boosters
date: 2022-05-26
journal: JAAD Case Rep
DOI: 10.1016/j.jdcr.2022.05.012
sha: cde5b27ac521686755aa596a8b00bb8704684d29
doc_id: 843609
cord_uid: 8pnf6zd1

nan

days after the initial dose of Pfizer BNT126b2 vaccine. These evanescent pruritic papules 13 resolved shortly prior to 2 nd dose. Four days after her 2 nd dose, she experienced similar but 14 more widespread pruritic eruption consisting of wheals of the upper body. These 15 lesions progressed over 2 weeks to large urticarial plaques over her upper and lower 16 extremities, chest, and abdomen. The reaction responded favorably to a six-day taper of 17 prednisone at a starting dose of 60mg from an outside provider on day 18 but rebounded when 18 discontinued. The pruritus improved slightly with loratadine, cetirizine and famotidine. At 19 the time of presentation, seven weeks after the second dose, urticaria persisted and the patient 20 was having difficulty sleeping. 21

Dermatopathology report from a punch biopsy indicated interstitial and perivascular 22 inflammatory infiltrate in dermis with abundant eosinophils consistent with urticaria. Laboratory 23 data revealed elevated IgE levels (288 IU/mL, reference value 0-100 IU/mL) and positive SARS-24

CoV-2 spike antibody. Complete blood count, liver function panel and basic metabolic panel 25 were all within reference ranges. 26

Timing of onset after vaccination, and the dose-response (starting after first dose, exacerbated by 27 second dose) are suggestive of COVID-19 vaccination induced chronic spontaneous urticaria. 28

The patient was continued on H1 and H2 blockers. Omalizumab was added at 150mg SQ for 4 29 weeks. This dosage resulted in partial response. The dose was subsequently increased to 300mg The patient had no significant medical history, had no prior history of atopy or urticaria, and was 44 on no medications at time of presentation. 45

The patient's urticaria significantly improved with separate trials of diphenhydramine and 46 cetirizine; however, the patient discontinued both due to side effects. Within 48 hours of 47 discontinuation, rebound rash appeared. The patient subsequently began 180mg fexofenadine 48 twice daily and 1,000 IU Vitamin D once daily which controlled symptoms. She was prescribed 49 20mg famotidine twice daily in the event of breakthrough pruritus, which did not occur while on 50 fexofenadine and Vitamin D therapy. 51

Laboratory data revealed positive screening antinuclear antibodies (ANA) (titer 1:320, 52 reference value < 1:80). Repeat ANA was negative (titer <1:80). Complete blood count, liver 53 function panel, basic metabolic panel, inflammatory markers including c-reactive protein and 54 erythrocyte sedimentation rate, tryptase levels, and TSH were within reference ranges. 

Cutaneous Adverse Reactions Dermatol

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