key: cord-0854101-2a4mrwul
authors: Grossman, Marc E.; Appel, Gerald; Little, Alicia J.; Ko, Christine J.
title: Post‐COVID‐19 vaccination IgA vasculitis in an adult
date: 2021-11-30
journal: J Cutan Pathol
DOI: 10.1111/cup.14168
sha: 6514691dfd3e7d17d953e8aa2df00468145b190a
doc_id: 854101
cord_uid: 2a4mrwul

Leukocytoclastic vasculitis has been reported in the setting of COVID‐19 infection and post‐COVID‐19 vaccination. We report a case of IgA vasculitis (IgAV) post‐COVID‐19 vaccination, with immunoglobulin A (IgA) immune deposits in the skin and renal involvement. SARS‐CoV spike protein immunohistochemical staining was negative. IgAV with skin and renal involvement is a potential reaction to COVID‐19 vaccination.

Cutaneous leukocytoclastic vasculitic reactions have been temporally associated with COVID-19 vaccines from various manufacturers, including Astra-Zeneca, Bharat, Jansen, Moderna, and Pfizer. [1] [2] [3] [4] [5] [6] The exact pathogenesis of these reactions is unclear, and perivascular immunoglobulin A (IgA) immune deposits have not been described previously, to our knowledge. Any direct relationship of small-vessel vasculitis with spike protein deposition is also unknown. There were no significant deposits of IgM, C3, IgG, or IgG4. There was no thrombotic vasculopathy. Immunohistochemical staining was negative for SARS-CoV-2 spike protein (using two different antibodies, SinoBiological, and GeneTex) and nucleoprotein (Thermo Fisher).

He was started on prednisone 60 mg/day given the creatinine that peaked at 2.4 mg/dL. There was rapid resolution of the skin rash, and his urinalysis and creatinine returned toward normal over the ensuing months.

IgA vasculitis (IgAV) may be idiopathic or associated with infection (bacterial or viral including SARS-CoV-2), medications, malignancy, or vaccination. Post-COVID-19 vaccination reactions include new-onset leukocytoclastic vasculitis or exacerbation of pre-existing vasculitis. 7, 8 In children, IgAV is the most common immunization-related vasculitis, with influenza vaccine being the most commonly associated vaccine with all types of vasculitic events. 9 In one case report of ANCA-associated vasculitis following influenza immunization, it was posited that hyperreaction to viral RNA in the influenza vaccine triggered a systemic vasculitis. 10 We were unable to document SARS-CoV-2 spike protein deposition within the skin sample, and hypothesize that the immune In one study, the most common malignancies associated with HSP/IgAV in the adult were non-small-cell lung, prostate, and renal cancer. 11 Our patient had previously undergone complete prostatectomy. HSP has been associated with Staphylococcus aureus infection and sepsis with or without endocarditis; our patient had a bioprosthetic aortic valve but no symptoms or signs of infectious endocarditis. HSP has been reported post-COVID-19 infection, 12, 13 and renal damage in such cases may be due to either direct kidney infection through angiotensin-converting enzyme-2 receptors expressed in tubular cells and podocytes or secondary to a COVID-19 cytokine storm resulting in endothelial and glomerular damage. 12 In our patient, the temporal relationship of his IgAV to vaccination and the rapid resolution of disease implicate mRNA-1273 vaccination as a trigger for IgAV.

We report a case of IgAV in an adult, presumed to be secondary to mRNA-1273 COVID-19 vaccination. The pathogenesis of this selflimited reaction is unclear, but in this one case, immunohistochemistry for SARS-CoV-2 spike protein was negative. Awareness, recognition, and future study of this potential post-vaccine reaction may help elucidate the underlying mechanisms. F I G U R E 3 IgA vasculitis, direct immunofluorescence study. IgA immune deposits within superficial and upper dermal blood vessels (Â400)

Cutaneous small vessel vasculitis following single-dose Janssen Ad26.COV2.S vaccination

Henoch-Schönlein purpura presenting post COVID-19 vaccination

Asymmetrical cutaneous vasculitis following COVID-19 vaccination with unusual eosinophil preponderance

Cutaneous reactions reported after Moderna and Pfizer COVID-19 vaccination: a registrybased study of 414 cases

Clinical and histopathological spectrum of delayed adverse cutaneous reactions following COVID-19 vaccination

Smallvessel vasculitis following Oxford-AstraZeneca vaccination against SARS-Cov-2

Reactivation of IgA vasculitis after COVID-19 vaccination

Leukocytoclastic vasculitis flare following the COVID-19 vaccine

A 19-year old man with IgA vasculitis after vaccination

Viral RNA in the influenza vaccine may have contributed to the development of ANCA-associated vasculitis in a patient following immunisation

Henoch-Schönlein purpura associated with malignancy in adults

IgA vasculitis with nephritis (Henoch-Schonlein purpura) in a COVID-19 patient

Hemorrhagic rash on the legs

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

Christine J. Ko https://orcid.org/0000-0003-2270-2524