key: cord-0908625-ml41tzbn authors: Oskay, T.; Isık, M. title: Leukocytoclastic vasculitis after the third dose of CoronaVac vaccination date: 2021-12-01 journal: Clin Rheumatol DOI: 10.1007/s10067-021-05993-0 sha: 78507875616c22e5bff8e7492cf265909d8c84b0 doc_id: 908625 cord_uid: ml41tzbn nan c/p-ANCA, antiphospholipid antibodies, and ENA panel -e.g. Jo1, U1-RNP-, SCL70-, Sm-, and Ro/La-antibodies. Cryoglobulin and screening for viral infections (hepatitis A, B, and C, CMV, EBV, Coxsackie, parvovirus B19, and HIV) were also negative. A nasal swab proved negative for the SARS-CoV-2 virus. CT scans of the thorax and abdominopelvic yielded normal results. Dermatopathologic examination of the skin biopsy was compatible with small vessel LCV in the dermis showing plump endothelial cells surrounded by a perivascular mixed inflammatory infiltrate with karyorrhectic debris and extravasation of red blood cells (Fig. 1C, D) . Direct immunofluorescence did not reveal any deposits in the vessels. His abdominal pain and stool tests on occult blood-positive favor occult bleeding associated with LCV of gastrointestinal involvement. From the correlation of the clinical presentation, laboratory findings, and recent COVID-19 vaccine, we established the diagnosis of cutaneous and gastrointestinal LCV, possibly triggered by the third dose of immunization, by excluding possible triggers such as concomitant medication, other infectious, malignant, and autoimmune causes. As our patient presented with pronounced skin and gastrointestinal involvement, we treated him with oral prednisolone at a dose of 0.5 mg/kg/day, with a rapid response. At a follow-up 14 days later, all clinical manifestations and laboratory findings were resolved. So far, cutaneous vasculitis presenting with typical skin lesions has been well reported in mild as well as fulminant COVID-19 infections. Vasculitis in COVID-19 has been attributed to SARS-CoV-2-associated endothelitis, which could be because of the virus directly invading the endothelium or owing to an inflammatory response that results in immune complex deposits in the vessels [1] . Recently, COVID-19 vaccinations associated with LCV and autoimmune adverse effects have been described, but they are relatively rare. The Coronavac vaccine (Sinovac, China) contains inactivated whole or split virion representatives of COVID-19 viruses, as well as several adjuvants (aluminum) that are unlikely to cause immunopathology. It's still unclear if it's a hypersensitivity reaction to the SARS-CoV-2 spike protein or the other vaccination component [2] . The COVID-19 vaccine may provoke hyper-activation of the immune system secondary to cross-reactivity and molecular mimicry between the virus and self-antigens, consequently triggering autoimmune disorders such as vasculitis in genetically predisposed individuals [3] . To our knowledge, there were few previous case reports of vaccine-associated reactivation or new-onset LCV or IgA vasculitis after COVID-19 with mRNA or inactivated SARS-CoV-2 vaccines at the first or second doses, but none at the third dose [4] [5] [6] [7] [8] [9] . In addition, in some case reports, mRNA COVID-19 vaccinations have been linked to newonset or recurrent ANCA-associated vasculitis with kidney impairment [10] . Compared to other reported cases, he developed GIS involvement and responded faster to corticosteroids. In our case, the large antigenic trigger because of the booster re-exposure of the third dose may have contributed to the development of cutaneous LCV with GIS involvement without known predispositions to the type 3 hypersensitivity. The purpose of this case report is to increase awareness of the potential side effects of the vaccine. However, more studies are needed to better characterize the adverse effects of these vaccines on elderly individuals. The authors contributed equally to all aspects of the article. Ethics approval and consent to participate Written informed consent was taken from the patient to present this case report. Disclosures None. Covid-19 pandemic and the skin Cutaneous adverse reactions to COVID-19 vaccines: insights from an immuno-dermatological perspective Covid-19 vaccine and autoimmunity: awakening the sleeping dragon Leukocytoclastic vasculitis flares following the COVID-19 vaccine New-onset leukocytoclastic vasculitis after COVID-19 vaccine Asymmetrical cutaneous vasculitis following COVID-19 vaccination with unusual eosinophil preponderance A case of leukocytoclastic vasculitis after vaccination with a SARS-CoV2-vaccine -a case report First description of immune complex vasculitis after COVID-19 vaccination with BNT162b2: a case report Emergence of de novo cutaneous vasculitis post coronavirus disease (COVID-19) vaccination ANCA-associated vasculitis following Pfizer-BioNTech COVID-19 vaccine Publisher's note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations