key: cord-0990174-oeuh7yxh
authors: Han, Joseph; Russo, Gerardo; Stratman, Scott; Psomadakis, Corinna E.; Rigo, Rachel; Owji, Shayan; Luu, Yen; Mubasher, Adnan; Gonzalez, Belen Rubio; Ungar, Jonathan; Harp, Joanna; Magro, Cynthia; Ungar, Benjamin; Lamb, Angela; Gulati, Nicholas
title: Toxic Epidermal Necrolysis-like Linear IgA Bullous Dermatosis after Third Moderna COVID-19 Vaccine in the Setting of Oral Terbinafine
date: 2022-05-07
journal: JAAD Case Rep
DOI: 10.1016/j.jdcr.2022.04.021
sha: 26083d182c3cb32e90df05ec712efdbfbcde58fc
doc_id: 990174
cord_uid: oeuh7yxh

nan

Two biopsies were performed at the right and left abdomen, including a frozen 76 section, which was read immediately by surgical pathology, showing an interface 77 dermatitis consistent with TEN. Terbinafine was emergently stopped, and the patient was 78 transferred to another hospital with a burn unit due to the working diagnosis of TEN. At 79 that hospital, repeat biopsies were performed on the right lower abdomen. H&E staining 80 showed a neutrophil-rich subepidermal blister, consistent with TEN-like presentation of 81 LABD, and the direct immunofluorescence (DIF) showed dominance of IgA at the 82 epidermal basement membrane zone, consistent with LABD ( Figure 3 ). During admission 83 in the second hospital, the permanent sections from the initial hospital were read by 84 dermatopathology as also consistent with LABD, but not TEN. 85

When the patient was transferred to the second hospital, she received 1000 mg of 86 IV methylprednisolone, which was tapered to 250 mg over five days. She was then 87 transitioned to oral prednisone starting at 80 mg daily, which was tapered over 10 days. 88

She also received topical triamcinolone 0.1% ointment twice daily to the trunk and 89 clobetasol 0.05% ointment twice daily to the arms and legs. During the course of her oral 90 prednisone taper on Day 20, the patient's rash resolved (Figure 4) . The patient was 91 closely observed in the hospital throughout her corticosteroid taper.

Given the patient's initially localized rash, and the temporal relationship of her 95 recent Moderna COVID-19 booster, which is speculated to cause autoimmune 96 manifestations, 4 we posit that her booster unmasked a subclinical hypersensitivity 97 syndrome, resulting in a TEN-like presentation of LABD possibly secondary to terbinafine. 98

Alternatively, it is possible that the terbinafine administration may have been coincidental 99 and that her presentation was entirely secondary to her COVID-19 vaccination. 

Linear IgA bullous dermatosis: 140 comparison between the drug-induced and spontaneous forms

Drug-induced linear immunoglobulin A 143 bullous dermatosis: A French retrospective pharmacovigilance study of 69 cases

Linear immunoglobulin A bullous dermatosis

Vesiculobullous skin reactions 150 induced by COVID-19 mRNA vaccine: report of four cases and review of the literature

Linear IgA bullous dermatosis 153

following Oxford AstraZeneca COVID-19 vaccine

COVID-19 vaccines: modes of immune activation and future 156 challenges

Role of the NLRP3 inflammasome in autoimmune diseases