key: cord-1014183-pax25fyu authors: Kharkar, V.; Vishwanath, T.; Mahajan, S.; Joshi, R.; Gole, P. title: Asymmetrical cutaneous vasculitis following COVID‐19 vaccination with unusual eosinophil preponderance date: 2021-07-29 journal: Clin Exp Dermatol DOI: 10.1111/ced.14797 sha: 9b1a8c3f6cdb866419981ad3be94103294ecb061 doc_id: 1014183 cord_uid: pax25fyu The COVID-19 pandemic has profoundly impacted life across the globe. Vaccines are perhaps the only silver lining in this dark cloud since they mitigate disease severity. As more people are vaccinated, however, various adverse events (AE) including cutaneous AEs have been reported. Cutaneous vasculitis is one such rare AE with few cases reported. We report a case of cutaneous small vessel vasculitis (cSVV) following COVID-19 vaccination with strikingly asymmetric distribution. Dear Editor, The COVID-19 pandemic has profoundly impacted people's lives across the globe. Vaccines are perhaps the only silver lining in this dark cloud as they mitigate the severity of the disease. However, as more people are vaccinated, various adverse events (AEs) including cutaneous AEs have been reported. Cutaneous vasculitis is one such rare AE with a few cases reported. We report a case of cutaneous small vessel vasculitis (cSVV) with a strikingly asymmetrical distribution, following COVID-19 vaccination. A 31-year-old woman presented with a 3-day history of painful purpuric lesions on her legs. She reported no comorbidities, systemic problems or prior medications. Her medical history was unremarkable apart from receipt of her second dose of inactivated viral vaccine (COVAXIN â ; Bharat Biotech, Hyderabad, India) 4 days prior to development of the lesion; she had not developed any similar lesion after the first dose, which had been given 4 weeks before the second dose. On examination, tender palpable purpura was noted predominantly on the left leg, with pitting oedema (Fig. 1a,b) . Dermoscopy revealed irregularly arranged red blotches with an orange-red background (Fig. 1c) . Histology showed an abundant upper and mid-dermal perivascular infiltrate comprised predominantly of eosinophils and lymphocytes with a few neutrophils, along with erythrocyte extravasation, perivascular fibrin and perivascular oedema (Fig. 2a,b) . The patient's financial constraints precluded direct immunofluorescence. Routine biochemical and immunological investigations were within normal limits. Reverse transcription (RT)-PCR for COVID-19 and throat swab were negative. The final diagnosis was cSVV secondary to COVAXIN â . The patient was advised rest and leg elevation, and prescribed antihistaminics for a week, after which the lesions resolved with hyperpigmentation. She is being followed up monthly and remains asymptomatic. Immunological phenomena with vaccines are not unknown, having been noted with hepatitis B, human papillomavirus and influenza vaccines. 1 This could be due to molecular mimicry and immunological crossreactivity due to vaccine antigens. 2 With the increase in the number of people receiving COVID-19 vaccines, multiple reports of cutaneous AEs to COVID-19 vaccines have emerged. The largest series of 414 patients described local reactions as the commonest AEs. 3 Only three cases of cutaneous vasculitis following COVID-19 vaccination have been reported. 3 Another report described a single patient with aggravation of preexisting vasculitis after mRNA vaccine. 2 There are The obvious asymmetry of the purpura in this case was intriguing. While working, our patient tended to sit with her right leg habitually crossed over the left, thus due to the resultant reduction of gravity and hydrostatic pressure, the purpura were less severe on the right leg. The few previous reports of similar cases also considered the cause to be the dependent position of the affected limb, while the limb which is kept horizontally tends to be spared. 4, 5 Eosinophil predominance, an unusual histopathological aspect of the present case, has been noted in only a few groups of diseases, 6 and has not been described previously in vaccine-induced vasculitis. Awareness and reporting of systemic and cutaneous AEs of vaccines by physicians is important. Further studies are needed to determine the association of vasculitis with vaccine constituents. A wait-and-watch policy in such cases could be adopted before further investigations, as in our patient resolution was noted in 10 days without recurrence. Vaccines and autoimmune diseases of the adult Leukocytoclastic vasculitis flare following the COVID-19 vaccine Cutaneous reactions reported after Moderna and Pfizer COVID-19 vaccination: a registry-based study of 414 cases Unilateral cutaneous vasculitis: an uncommon presentation and a possible explanation Unilateral purpuric rash in a patient with acute renal failure Eosinophils in vasculitis: characteristics and roles in pathogenesis We thank the patient for their written informed consent to publication of the case details.